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From the 11/26/2021 release of VAERS data:

This is VAERS ID 975023

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Case Details

VAERS ID: 975023 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-25
Onset:2021-01-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Dyspnoea, Influenza A virus test negative, Influenza B virus test, Influenza virus test negative, Respiratory syncytial virus test negative, SARS-CoV-2 test negative, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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 20MG DAILY, GABAPENTIN 300MG TWICE DAILY, HYDRALAZINE 10MG 3 TIMES DAILY, LANTUS 30UNITS AT BEDTIME, LUMIGAN OPHTHALMIC SOLN BOTH EYES EVERY EVENING, METOLAZONE 2.5MG DAILY, OMPERAZOLE 20MG DAILY, PREDNISONE 15MG DAILY, TORSEMI
Current Illness:
Preexisting Conditions: PULMONARY FIBROSIS, HYPERTENSION, DIABETES MELLITUS, COPD, TOBACCO USE, ALCOHOL INTAKE, RESPIRATORY FAILURE, PVD, PROTEINURIA, PERICARDITIS, HYPERLIPIDEMIA, OBESITY, ILD, HYPONATREMIA, CKD STAGE 3, BPH, ANEMIA, BILATERAL HEARING LOSS, GERD, HYPERSENSITIVITY PNEUMONITIS, DIASTOLIC CONGESTIVE HEART FAILURE, SOLITARY PULMONARY NODULE
Allergies: SULFA, IODINE-BASED CONTRAST MEDIA
Diagnostic Lab Data: SARS-CoV-2 by PCR - NEGATIVE, FLU-A./B/RSV NEGATIVE
CDC Split Type:

Write-up: CARDIAC ARREST THAT LEAD TO DEATH - IT WAS REPORTED BY EMS THAT THE PT HAD RECEIVED THE VACCINE ABOUT 30 MINS PRIOR. HE ARRIVED HOME, BECAME SHORT OF BREATH & COLLAPSED. 911 WAS CALLED AND HE WAS TRANSPORTED VIA EMS TO HOSPITAL (16:17) WHERE HE LATER EXPIRED (23:01).


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