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From the 5/7/2021 release of VAERS data (an older release, current is 11/12/2021):

This is VAERS ID 1116594

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Case Details

VAERS ID: 1116594 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-03-04
Onset:2021-03-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / UNK - / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Death, Hypoxia, Respiratory arrest, Respiratory distress, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Warfarin
Current Illness: Unknown
Preexisting Conditions:
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient called EMS from for respiratory distress. EMS arrived, noted severe distress and hypoxia. Patient transported to Hospital Emergency Dept. Patient deteriorated to respiratory arrest and cardiac arrest. Per ED note, after 30 minutes of aggressive resuscitation (including approximately 19 minutes in the ED), no ROSC was achieved. Patient expired


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1116594


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