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

This is VAERS ID 1120493



Case Details

VAERS ID: 1120493 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-06
Onset:2021-03-10
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029A21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac arrest, Death, Pulse absent, Resuscitation
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: 2021-03-10
   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: Lisinopril (40mg daily), Glyburide (500mg daily); (Valsartan 320mg daily)
Current Illness:
Preexisting Conditions: Type-2 Diabetes; Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cardiac arrest five days after administration of the 2nd dose at 9pm, ambulance was called and EMTs attempted resuscitation, but no pulse was detected after 1 hour of compressions and CPR; time of death was recorded at 10:06pm


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1120493

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