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

This is VAERS ID 1054080



Case Details

VAERS ID: 1054080 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-18
Onset:2021-02-21
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   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: amlodipine, centrum silver, vitamin C, Vitamin D, vitamin E, zinc, Lexapro, Seroquel, trazodone.
Current Illness: none
Preexisting Conditions: hypertension, COPD, schizophrenia
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: cardiac arrest, death: 2/21/21


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1054080

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