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From the 5/14/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1050281

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Case Details

VAERS ID: 1050281 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-09
Onset:2021-02-01
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19 pneumonia, Cardiac arrest, Death, Malaise, X-ray abnormal
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), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 MG Tablet Delayed Release, 1 Tablet Orally once a day Norvasc 10 MGTtablet, 1 Tablet orally once a day Lisinopril 20 MG Tablet, 1 Tablet orally once a day Terazosin HCl 10 MG tablet, 1 tablet orally once a day Metformin HCl 1000
Current Illness:
Preexisting Conditions: Z86.39 History of vitamin D deficiency Z99.89 Uses continuous positive airway pressure (CAPAP) ventilation at home E11.40 Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin I10 HTN (hypertension) N40.0 BPH (benign prostatic hyperplasia E11.29 Microalbuminuria due to type 2 diabetes mellitus Z87.09 Hx of emphysema G47.33 Severe obstructive sleep apnea G47.30 Sleep apnea H25.13 Age-related nuclear cataract, bilateral Z68.36 BMI 36.0-36.9, adult I83.813 Varicose veins of both lower extremities with pain E00.36 Type 2 diabetes mellitus with diabetic cataract, without long-term current use of insulin
Allergies:
Diagnostic Lab Data: X-rays were taken at Medical Center, Patient was diagnosed with Cardio arrest secondary to COVID-19 pneumonia.
CDC Split Type:

Write-up: Per family, patient has been feeling sick since he was vaccinated, patient went to ER on 02/15/2021, and after few hours at ER patient passed away.


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