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

This is VAERS ID 957116

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Case Details

VAERS ID: 957116 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-01-14
Onset:2021-01-18
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Military       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Atovastatin, Ferrous sulfate, Finasteride, Flomax, Humulin N, Pantoprazole, ProAir, Reglan, Spiriva, Turmeric
Current Illness: Diabetes, Chronic renal failure on hemodialysis, Atrial fibrillation, Quadriplegia, Thrombocytopenia, Gastroparesis, Vitamin D deficiency, BPH, Neurogenic bladder, distant history of small intestine carcinoid tumor, right cerebral artery aneurysm, Barrett''s esophagus, MGUS, Hypertension, obstructive sleep apnea, Pulmonary hypertension, Junctional tachycardia.
Preexisting Conditions: see above. Sudden death without warning likely due to medical problems above but spouse feels it was somehow related to the vaccine 4 days before and it is a new vaccine.
Allergies: Cipro caused nausea, Coreg caused bradycardia, Hydrocodone, calcium acetate
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Sudden death without warning symptoms 4 days after vaccine. Many medical problems which most likely explain the outcome but spouse feels it is related and it is a new vaccine. Monitor for pattern?


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