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

This is VAERS ID 1177173



Case Details

VAERS ID: 1177173 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-04-05
Onset:2021-04-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018B21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Feeling hot, Nervousness, Resuscitation
SMQs:, Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   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:
Current Illness:
Preexisting Conditions: MULTIPLE STENTS, HEART PROBLEMS, HYPERTENSION
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Husband and wife came in 4/5 and received their COVID vaccines at 11am. They waited the 15 minutes to check for reactions and were unsymptomatic when time was up. The pharmacy did a courtesy call around 3:15 pm on 4/7 to check in with them and see how they were feeling. The wife stated that her husband had passed away the night of 4/5. Wife stated that they were getting ready to go to bed and husband felt hot and shaky so he laid in front of a fan. Wife eventually had to do CPR and stated that she thinks that he passed away during the time while they were waiting for EMS, which took about 45 minutes. Patient was pronounced dead night of 4/5. Wife stated that patient has a history of heart problems including hypertension and multiple stents place and that she does not think the vaccine had to do with her husband''s death.


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