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

This is VAERS ID 1053694



Case Details

VAERS ID: 1053694 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-08
Onset:2021-02-17
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tamsulin, Xarelto, Lasix
Current Illness: A-FIB, DM2,
Preexisting Conditions: DM2, A-FIB
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sudden Death on 2/17/2021


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1053694

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