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

This is VAERS ID 1126609



Case Details

VAERS ID: 1126609 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-03-17
Onset:2021-03-19
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Drug screen negative, Haemoglobin normal, Platelet count decreased, Red blood cell count normal, Thrombosis, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haematopoietic thrombocytopenia (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: none known by family who showed up at ED.
Current Illness: ETOH ABUSE, TOBACCO ABUSE, DIABETES,
Preexisting Conditions: DIABETES, TOBACCO AND ETOH ABUSE, SOME UNKNOWN LIVER DISEASE BY FAMILY REPORT-ON ONE KNOWS THE NAME OF IT.
Allergies: none known
Diagnostic Lab Data: CBC: WBC 12.8, RBC 4.82, HGB,15.0, HCT 46.0, PLATELETS 29 (LL)-BLOOD WAS CLOTTED, PT WAS DOA. DRUG SCREEN ALL NEGATIVE
CDC Split Type:

Write-up: CARDIOPULMONARY ARREST 2 DAYS AFTER RECIEVING SECOND MODERNA DOSE


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