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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 998421

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Case Details

VAERS ID: 998421 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-06
Onset:2021-01-27
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Sudden cardiac death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: acetaminophen aspirin- 81mg calcium carbonate carbidopa-levodopa cholecalciferol fenofibrate fluorouracil cream fluticasone nasal spray folic acid nitroglycerin PRN miralax
Current Illness: Basal cell carcinoma of right ear
Preexisting Conditions: Parkinson''s CAD Labile HTN Renal artery stenosis HLD Basal cell carcinoma Squamous cell carcinoma BPH Prostate CA Urge incontinence Mild cognitive impairment
Allergies: Verapamil Amlodipine Morphine Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident passed away unexpectedly on 1/27/21 from presumed sudden cardiac death.


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