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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1237511

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Case Details

VAERS ID: 1237511 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: New York  
Vaccinated:2021-04-18
Onset:2021-04-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039B21A / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Anticoagulant therapy, Asthenia, Breath sounds abnormal, Cardiac arrest, Chest X-ray abnormal, Computerised tomogram head normal, Endotracheal intubation, Lung opacity, Pneumonia aspiration, Therapeutic hypothermia, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-20
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol 300mg tablet, amiodarone 200mg tablet, aspirin 81mg tablet, atorvastatin 40mg tablet, carvedilol 12.5mg tablet, clopidogrel 75mg tablet, folic acid 1mg, Levemir, Humalog, losartan-HCTZ 100/25mg tablet, omeprazole 40mg capsule, p
Current Illness:
Preexisting Conditions: Diabetes Mellitus Type 2, ICD Pacemaker, Renal disorder, gout
Allergies: Unable to assess at the time of hospitalization
Diagnostic Lab Data: CT Head done - no acute findings suggestive of stroke, hemorrhage Chest XRay showed Bilateral R$gL opacities and lung sounds coarse
CDC Split Type:

Write-up: Patient brought in by ambulance after cardiac arrest witnessed by patient''s wife at 4/19/21 1:37AM. Per ED, the wife reports he had complained of feeling weak over the last few days without clear reason, then this morning patient had episode of emesis after which he told wife to call 911 and then suddenly became unresponsive. In ED was intubated, started on hypothermia protocol, Patient sedated on Propofol and started on a heparin drip, clopidogrel, aspirin and empiric antibiotics for aspiration Pneumonia


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