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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1050431



Case Details

VAERS ID: 1050431 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-26
Onset:2021-02-02
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 - / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Bradykinesia, Fall, Pulse absent, Resuscitation, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (narrow), Accidents and injuries (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: To the best of my knowledge these are the drugs he took that morning. Furosemide 20 mg; Isosorbide Mononitrate-ER 60 mg; Calcitrol .25 mcg; Levothyroxine - .15 mg; Folic Acid 800 mcg; MultiVits; Metamucil 525 mg capsule; Metroprolol ER -
Current Illness: None
Preexisting Conditions: Heart disease, diabetes in the past but not for the past 4 years; had 3 toe amputations; poor circulation in his legs.
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Since I was not with my husband I can only tell you what was told to me. He walked out of the store toward our car. Someone watched him, concerned, because he was walking very slowly (normally has a slow gait because of leg braces and toe amputations so I don''t know if it was unusually slow). The woman saw him fall and she ran to help-administered CPR immediately-and told me he died instantly. Medics tried to resuscitate and failed to bring a pulse. (My husband left our home around 11:15 to drop a package off at store. The store is one mile from our home. At around 12:30 a deputy came to my door and when I saw him my knees buckled. I knew something horrible happened.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1050431

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