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

This is VAERS ID 1002813



Case Details

VAERS ID: 1002813 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-02-03
Onset:2021-02-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 062G20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood pressure increased, Cardiac arrest, Death, Heart rate increased, Respiratory arrest, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (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), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: Alphagan gtts, aricept, colace, D3-50, Depakote, levetiracetam, metoprolol,senna, tylenol
Current Illness: None
Preexisting Conditions: medical diagnosis chronic conditions Epilepsy, alzehimer''s disease, acute resp. failure, non-st MI,encephalopathy, ETOH use, claucoma, anxiety/depression, HTN, macular degeneration, extropia, presbyopia, hearing loss,
Allergies: no allergies
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient was seen at 0710 he was sleeping but at normal cognitive behavior Patient was again assessed at 0720 where he was noted to be unresponsive, BP 180/100s, HR 230s, he was a DNR therefore not CPR was administered. EMS arrived at facility patient was noted to be in full cardiac and respiratory arrest. Time of death 0735


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