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

This is VAERS ID 1061184



Case Details

VAERS ID: 1061184 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-14
Onset:2021-02-05
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20AMODERNA / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cold sweat, Dizziness, Echocardiogram, Fatigue, Headache, Hyperhidrosis, Myocardial infarction, Pain, Pain in extremity
SMQs:, Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Vestibular disorders (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ASA Atorvastatin Lisinopril
Current Illness: none
Preexisting Conditions: Hyperlipidimia Hypertension
Allergies: NKDA
Diagnostic Lab Data: Echocardiogram 2/25/21
CDC Split Type:

Write-up: Possible heart attack on 2/5/21. Complaint: " On Feb 5th l believe l experienced a mild hear attack" (Comment: He said he felt "clammy, sweaty, excruciating pain on my left side - including his left arm, and left leg, dizzy, exhausted." This happened after work, and after taking a shower. He said that was the first time he''s experienced it, and that it has not happened since then. He said he has constant headaches, "It just went away yesterday."


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