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

This is VAERS ID 1055819

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Case Details

VAERS ID: 1055819 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Arizona  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Cardiac arrest, Dyspnoea, Gait inability, Laboratory test normal, Mechanical ventilation, Pyrexia, Sudden death, Vaccination complication
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dystonia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 39 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Taking various meds/antibiotics for UTI, CDIF, high sodium, high blood pressure, diabetes
Current Illness: Treated for COVID pneumonia. Tested positive on Jan 2, 2021. This caused other infections (UTI, CDIF), required oxygen.
Preexisting Conditions: Treated underlying conditions for diabetes, high sodium, high blood pressure, kidney disease.
Allergies: NA
Diagnostic Lab Data: See above
CDC Split Type:

Write-up: On January 1, 2021, patient was admitted to Medical Center with COVID. Tested positive on January 2, 2021. Spent 10 days in hospital. Once recovered from pneumonia and fever gone, on January 10, 2021, she was transferred to Rehabilitation Center for continued treatment. She spent 16 days there. She developed UTI and CDIF infections and was on/off oxygen. She started physical therapy. She was scheduled to be released to go home on January 27, 2021. On January 26, 2021, the day before going home, Rehabilitation Center gave her the Moderna vaccine. On January 27, the day she went home, she started feeling very weak and couldn''t walk. My dad tried lifting her and they both fell to the ground. My dad called 911 and she was taken to Medical Center, with high fever and possible stroke symptoms (which later was negative). Two days later, she had difficulty breathing and was put on a ventilator. She was on a ventilator for about three days. They took it off and she slowly started recovering. The doctors did all kinds of tests (blood clot in lung, heart, etc.) and all was negative. The only thing they could trace it to was an adverse reaction to the vaccine. After spending 11 days at hospital and treating her for various infections, her heart stopped and she passed away suddenly.

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