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From the 5/14/2021 release of VAERS data (an older release, current is 10/15/2021):

This is VAERS ID 1074955



Case Details

VAERS ID: 1074955 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-02-13
Onset:2021-02-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 RA / IM

Administered by: Military       Purchased by: ?
Symptoms: Death, Fall, Feeling abnormal, Head injury, Muscular weakness, Respiratory arrest, Resuscitation
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Dementia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   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: Metroprolol, zetia, Multag for AFIB, metformin,lisinopril, Immodium, Atorvastatin, was on a blood thinner but stopped 1/25/21
Current Illness: DX with Covid -19 on Jan 2, 2021, had surgery on Jan 28th, 2021 to remove scar tissue between the bladder and prostate.
Preexisting Conditions: Afib, diabetes, hypertention, blood clotting disorder
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: at midnight client got up to go to the bathroom. His legs became weak and he fell and hit his head on the wall. He called for his wife and said he didn''t feel right. He denied any pain. She called EMSA and he stopped breathing while she was waiting on them. She gave him CPR with instructions from the dispatcher. He was pronounced dead at 1:30am. She has tried to call the clinic 3 times and left messages and no one has called her back, Her PCP told her this needed to be reported .


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210514&IDNUMBER=1074955

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