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From the 5/7/2021 release of VAERS data:

This is VAERS ID 1125300



Case Details

VAERS ID: 1125300 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-19
Onset:2021-03-21
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 623MZ0A / 1 UN / UN

Administered by: Private       Purchased by: ?
Symptoms: Arrhythmia, Cardiac pacemaker insertion, Death
SMQs:, Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   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: Allopurinol, Eliquis, Furosemide, Imdur, Lisinopril, Crestor, Shingrix, and Tamsulosin.
Current Illness: None.
Preexisting Conditions: Essential hypertension, tachy-brady syndrome, supraventricular tachycardia, atrial flutter, and sinus node dysfunction. He also had a pacemaker implanted on 03/19/2021.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had no known ill effects or complaints directly after receiving his first COVID-19 vaccine on 02/19/2021. However, on 03/21/2021, he was found deceased on his bedroom floor due to a suspected cardiac arrhythmia. It is unknown if there is any correlation.


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