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From the 1/14/2022 release of VAERS data:

This is VAERS ID 971176

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Case Details

VAERS ID: 971176 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-20
Onset:2021-01-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Autopsy, Cardiac arrest, Death, Fatigue, Livedo reticularis, Malaise, Respiratory arrest, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (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), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: atorvastatin 10 mg avodart 0.5 mg finasteride 5 mg colace 100 mg fish oil capsule over the counter nabumetone 750 mg omiprazole 20 mg tamsulosin 0.4 mg calcium plus D3 over the counter
Current Illness: last doctor visit on 10/27/2020 and no illness at that time, routine follow up
Preexisting Conditions: BPH reflux (Gerd) Osteoarthritis high cholesterol
Allergies: none
Diagnostic Lab Data: Autopsy being done.
CDC Split Type:

Write-up: Pt. woke up the next morning after vaccination and "didn''t feel well", described by wife as fatigue, no energy. At approximately 2 PM, he vomited. His wife checked on him at 4:20 PM and he wasn''t breathing sitting in his chair. EMS squad was called but when they arrived he was asystole and mottling present. Did not start CPR since he was already gone too long. Pronounced by coroner on scene.


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