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From the 4/30/2021 release of VAERS data:

This is VAERS ID 1002187



Case Details

VAERS ID: 1002187 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-02
Onset:2021-02-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Resuscitation
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), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT WAS IN CLINIC FOR 1ST CLINIC. WAS DISCHARGED BEFORE OUR 2ND CLINIC. HE CAME BACK TO OBTAIN HIS 2ND SHOT. WE WENT OUT TO THE CAR GAVE SHOT. THE NEXT DAY TO MY KNOWLEDGE, HE STARTED CODING AT HOME. AMBULANCE WAS CALLED AND HE CONTINUED TO CODE. THE AMBULANCE CREW TRIED CPR FOR 30 MINS WITH NO LUCK. PATIENT PASSED 2-3-21.


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