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

This is VAERS ID 1082667



Case Details

VAERS ID: 1082667 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-02-08
Onset:2021-02-11
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 300042721 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest
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: 2021-02-11
   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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: ITMODERNATX, INC.MOD20210

Write-up: Arresto cardio-circolatorio; A regulatory authority report (Italy) was received from a physician concerning a female patient of 87-year-old, who was received Moderna''s COVID-19 vaccine(mRNA-1273) and experienced arrest cardiac. The patients'' medical history was not provided. No relevant Concomitant medications were reported. On 08 Feb 2021, prior to the onset of event, the patient received their first of two planned doses of mRNA-1273(Lot number: 300042721) vaccine intramuscularly for prophylaxis of COVID-19 infection. On 11 Feb 2021, the patient experienced cardiac arrest and passed away. The event was also considered medically significant. Treatment information was not provided. Action taken with the mRNA-1273 was not applicable. The outcome of event was fatal as patient died on 11 Feb 2021 due to arresto cardio-circolatorio. The autopsy details were not provided.; Reporter''s Comments: Very limited information regarding the event has been provided at this time and is insufficient for causality assessment. The autopsy details were not provided. However, the patient''s age may be a confounding factor for causality assessment.; Reported Cause(s) of Death: Arresto cardio-circolatorio


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