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

This is VAERS ID 1211889

Case Details

VAERS ID: 1211889 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA G26761A / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Body temperature, Cardiac arrest, Embolism, Pyrexia, Seizure
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 3
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: Medical History/Concurrent Conditions: SARS-CoV-2 infection (mild COVID-19 course)
Diagnostic Lab Data: Test Date: 20210227; Test Name: Body temperature; Result Unstructured Data: FATAL; Test Date: 20210302; Test Name: Body temperature; Result Unstructured Data: FATAL

Write-up: Sudden cardiac arrest; Seizures; Embolism; Body temperature increased to 39.7; Subfebrile body temperature; This regulatory authority case was reported by a consumer and describes the occurrence of CARDIAC ARREST (Sudden cardiac arrest), SEIZURE (Seizures), EMBOLISM (Embolism), PYREXIA (Body temperature increased to 39.7) and PYREXIA (Subfebrile body temperature) in a 77-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. G26761A) for COVID-19 vaccination. The patient''s past medical history included SARS-CoV-2 infection (mild COVID-19 course) from October 2020 to November 2020. Previously administered products included for an unreported indication: ELIQUIS. On 25-Feb-2021, the patient received dose of mRNA-1273 (COVID 19 Vaccine Moderna) (unknown route) at an unspecified dose. On 27-Feb-2021 at 1:00 PM, after starting mRNA-1273 (COVID 19 Vaccine Moderna), the patient experienced PYREXIA (Subfebrile body temperature) (seriousness criterion death). On 02-Mar-2021, the patient experienced CARDIAC ARREST (Sudden cardiac arrest) (seriousness criterion death), SEIZURE (Seizures) (seriousness criterion death), EMBOLISM (Embolism) (seriousness criterion death) and PYREXIA (Body temperature increased to 39.7) (seriousness criterion death). The patient died on 02-Mar-2021. The reported cause of death was sudden cardiac arrest. An autopsy was not performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 27-Feb-2021, Body temperature: 37.5 degree Celsius (abnormal) Fatal. On 02-Mar-2021, Body temperature: 39.7 degree Celsius (High) Fatal. The action taken with mRNA-1273 (COVID 19 Vaccine Moderna) (Unknown Route) was unknown. Treament was not reported/ unknown. Reporter did not allow further contact; Sender''s Comments: This is a case of death in a 77-year-old male subject with a medical history of recent SARS-CoV-2 infection but unknown other conditions, who died 5 days after receiving a dose of vaccine. Very limited information has been provided at this time. No follow up is possible.; Reported Cause(s) of Death: Sudden cardiac arrest

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