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

This is VAERS ID 1176896



Case Details

VAERS ID: 1176896 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-02-04
Onset:2021-03-04
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death
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: 2021-04-06
   Days after onset: 32
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan Potassium 50mg PO q day Claritin 10mg po q day Calcium 600mg PO q day CO Q 10 ASA 81mg q day
Current Illness:
Preexisting Conditions: History of Prostate Cancer
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died of an apparent Cardiac Arrest.


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