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From the 5/7/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 1236785

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Case Details

VAERS ID: 1236785 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-04-16
Onset:2021-04-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Cardioversion, Death, Resuscitation, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   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: ASA, Tramadol, Eliquis, Proscar, Carvedilol, Atorvastatin,Tamsulosin, Colchicine, Fenofibrate, Thiamine, Lisinopril, Folic Acid, Glimepiride
Current Illness: cellulitis and abcesses of Lower extremeties. pressure ulcers
Preexisting Conditions: Type 2 DM, Essential HTN, BPH, CKD Stage 3, Hyperlipidemia Anemia, ASHD, Gout, Peripheral artery disease,Arterial stenosis, pacemaker ( inserted 1/27/2021), Atrial fibrillation recent with TEE cardioversion 3/31/2021, cellulitis and abcesses of the lower extremeties, pressure injuries-unstageable to bilateral heels and side of the foot., S/P PTA of the right peroneal artery (1/2021) , fall March 2021
Allergies: Oxycodone
Diagnostic Lab Data: N/A -
CDC Split Type:

Write-up: Resident found unresponsive and without vital signs the morning on April 17, 2021 at 6:35am. The nurse started CPR, called a code, 911 called, AED applied. Local EMS responded, took over the code. EMS had contact with the local hospital ER, code called at the facility. Resident expired.


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