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

This is VAERS ID 1172648



Case Details

VAERS ID: 1172648 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-16
Onset:2021-03-23
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Cardio-respiratory arrest, Chest tube insertion, Death, Fibrin D dimer increased, Life support, Pulseless electrical activity
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage laboratory terms (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), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-23
   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: unk
Current Illness: no
Preexisting Conditions: NIDDM, HTN, CKD, obesity, lymphedema, chronic non pressure ulcer
Allergies: Erythromycin
Diagnostic Lab Data: DDimer 55, 000 thouand
CDC Split Type:

Write-up: Cardiopulmonary arrest, D-Dimer 55,000, TNKase administered, ACLS, needle thoracostomy, persistent PEA arrest, decompensated into asystole , pronounced


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1172648

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