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From the 3/19/2021 release of VAERS data (an older release, current is 10/15/2021):

This is VAERS ID 1095238



Case Details

VAERS ID: 1095238 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-03-08
Onset:2021-03-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Dyspnoea, Oedema, Oxygen saturation decreased, Resuscitation, Tachycardia, Unresponsive to stimuli
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   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: Lasix 40 mg daily, Potassium 10 meq daily, Novolin 70/30 insulin, gabapentin 600 mg BID, metformin 500mg BID, Naprosyn 500 mg BID, Lisinopril 20 mg daily, incruse ellipta and fluticasone/ salmeterol inhalers
Current Illness: covid positive 9/14/20, recently worsening of congestive heart failure with edema and shortness of breath for previous week
Preexisting Conditions: sarcoidosis, COPD, diabetes, HTN, congestive heart failure
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient at the time of vaccination on 3-8-21 has having issues with shortness of breath and edema consistent with congestive heart failure, the following day on 3-9-21, he was having more issues with shortness of breath, tachycardia, low O2 saturation. He was given meds in the clinic and monitored until he was feeling better with increased O2 sats. He was found unresponsive on his housing unit one hour later and failed to respond to resuscitation efforts and was pronounced expired at 1047.


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210319&IDNUMBER=1095238

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