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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1170711



Case Details

VAERS ID: 1170711 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-02-04
Onset:2021-02-28
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA G26761A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   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: LERCATON; ASPIRIN
Current Illness: Hypercholesteraemia; Hypertension; Osteoporosis
Preexisting Conditions: Medical History/Concurrent Conditions: Gonarthrosis; Myocardial ischaemia
Allergies:
Diagnostic Lab Data:
CDC Split Type: HUMODERNATX, INC.MOD20210

Write-up: Death; A Agency Regulatory Authority report was received from a Physician, concerning, a 88-year old female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and died/ Sudden death. The patient''s medical history included myocardial ischaemia, gonarthrosis, osteoporosis, hypercholesteraemia and hypertension. Concomitant medication included lercanidipine hydrochloride and acetylsalicylic acid On 04-FEB-2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (Lot number G26761A) intramuscularly for COVID-19 infection prophylaxis. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 28-Feb-2021.The cause of the death was unknown. Plans for an autopsy was unknown. The reporter had assessed the causality between the event and mRNA-1273 as unlikely.; Sender''s Comments: Very limited information regarding this event has been provided at this time and a causal relationship cannot be excluded; Reported Cause(s) of Death: Unknown cause of death


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