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

This is VAERS ID 1365007

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Case Details

VAERS ID: 1365007 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Male  
Location: Connecticut  
Vaccinated:2021-01-18
Onset:2021-01-23
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-06-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest
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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unk
Current Illness: unk
Preexisting Conditions: weakened immune system
Allergies: no
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: I do not know the individuals medical hx or illness/complications. Due to new information circulating related to mRNA vaccines and myocarditis/pericarditis and being made aware that this person had suffered cardiac arrest after being admit to the hospital following complications with their health it warrants being reported regardless of prior health conditions.


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