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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1274675



Case Details

VAERS ID: 1274675 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-04-23
Onset:2021-04-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046A21A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood glucose decreased, Cardiac arrest, Death, Moaning, Resuscitation
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), Hypoglycaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-23
   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: Humalog Lactulose 20 gram/30 mL solution Lumigan (bimatoprost) 0.01% drops Midodrine 10 mg tablet Rena-Vite Renvela 800 mg Sertraline 50 mg tablet
Current Illness:
Preexisting Conditions: Type 2 Diabetes, Hypertension, Hyperlipidemia, ESRD, Anemia, Hypothyroidism, Coronary Artery Disease, Cardiomyopathy, Liver Cirrhosis, GERD, Anxiety, Depression
Allergies: No know drug allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine was administered at 1215, patient was monitored for 15minutes per CDC guidelines with not adverse reactions noted. Approximately one hour after administration of vaccine patient noted to be moaning, fingerstick BS at 59mg/dL, Dextrose administered, pt proceeded in to cardiac arrest, CPR was initiated and EMS activated. Pt expired approximately 4 hours after incident at ER.


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