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From the 5/7/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1049963

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Case Details

VAERS ID: 1049963 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-12
Onset:2021-01-22
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Myocardial infarction, Pulse absent, Respiratory arrest, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: chlorpromazine 800mg QHS amantadine 100mg BID divalproex 1000mg QAM, 1500mg QHS haloperidol decanoate 225mg Q2weeks amlodipine 5mg QHS carvediol6.25mg BID docusate sodium 250mg BID fluticasone propionate 1 spray each nostril BID lisinopril
Current Illness:
Preexisting Conditions: obese, pre-diabetic, hypertension, atherosclerotic disease, coronary artery blockage, schizoaffective disorder Tested COVID-19 positive on 1/21/2021, asymptomatic, 1-1/2 weeks after first COVID-19 vaccination
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Found lying face down without respiration or pulse, believed to be within 5 minutes of event. ACLS procedures unsuccessful. Unable to get autopsy. Believed to be heart attack secondary to COVID infection, but unconfirmed. Relative contribution of recent vaccination unknown.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1049963


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