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

This is VAERS ID 1079958



Case Details

VAERS ID: 1079958 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-05
Onset:2021-03-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Multiple organ dysfunction syndrome, Pulse absent, Pulseless electrical activity, Resuscitation
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Cardiac arrhythmia terms, nonspecific (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atenolol, Oxycodone, Pepcid, Prevacid, Tessalon Perles, Trospium, Gabapentin, MEthotrexate, Plaquenil, Prilosec,
Current Illness:
Preexisting Conditions: HTN, RN, GERD, Potherpetic Neurology, GERD, Metatarsalgia, Knee joint Pain, Detrusor Instability, Viral meninigitis,
Allergies: Lime, PCN, Septra
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt found down and pulseless in home by husband. EMS called, Pt found to be in PEA arrest. Pt achieved ROSC with CPR and Epinephrin. Pt Passed away on 09/07/2021 at 1330. Pt was in multisystem organ failure.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1079958

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