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

This is VAERS ID 1271212

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Case Details

VAERS ID: 1271212 (history)  
Form: Version 2.0  
Age: 29.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-04-12
Onset:2021-04-22
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Cardiogenic shock, Death, Echocardiogram, Laboratory test
SMQs:, Cardiac failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Clonazepam, Ambien, Transene
Current Illness: Asma , Anxietyy
Preexisting Conditions: On admission time was found with ejection fraction of 16%
Allergies: NONE
Diagnostic Lab Data: ECHO-CARDIOGRAM BLOOD TEST
CDC Split Type:

Write-up: PATIENT DEVELOP CARDIOGENIC SHOCK AFTER RECEIVED FIRST DOSE OF MODERNA VACCINE ON THURSDAY 29 2021 PATIENT DIED


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