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From the 1/22/2021 release of VAERS data (an older release, current is 1/7/2022):

This is VAERS ID 956994

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Case Details

VAERS ID: 956994 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-15
Onset:2021-01-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Dyspnoea, Rash
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cholecalciferol, duloxetine, fenofibrate, gabapentin, hydrocortisone suppository, melatonin, metformin, metoprolol succinate, mineral oil, nitroglycerin, omeprazole, pravastatin, quetiapine, selenium sulfide shampoo, quetiapine, sumatriptan
Current Illness:
Preexisting Conditions: Hypertension, Type II diabetes, hyperlipidemia, GERD
Allergies: Aspirin, penicillin, vicodin, acetaminophen, niacin
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient had severe shortness of breath resulting in cardiac arrest on the 5th day after the vaccine. Shortness of breath started 12 hours after injection. On the 5th day, the patient was discovered to also have a rash throughout his body, but it is unknown when this rash started.


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