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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1022529

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Case Details

VAERS ID: 1022529 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Wisconsin  
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Respiratory arrest, Resuscitation
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 (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: Venlafaxine Hcl ER 150 daily, Multi vitamin, Aspirin 81mg, Nitro 0.4 prn, Vitamin E 200 daily, Ipratropium-Albuterol 0.5-2.5 inhalation q 6 hrs, omeprazole 20mg daily, isorbide monintrate ER 60mg daily, spironolactone 50mg , mens multi vita
Current Illness: pt was seen 1/8/21 for a Scatica flare Pt had a follow up colonscopy performed 1/21/21 where a couple polyps were found and diverticulosis
Preexisting Conditions: pt has COPD and used Oxygen at night, Coronary atherosclerosis, Diabetes Type 2, hypertriglyceridemia, OSA, hyperlipidemia, hypertension, IBS, pulmonary emphysema, acute or chronic heart failure, morbid obesity, atrial fibrillation, depression, hypercholesteremia, stage 3 kidney disease
Allergies: Amoxicillin(rash), Lisinopril (cough)
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pt suffered Cardiac Arrest and respiratory arrest on 2/9/21 and passed away at a local hospital. He had multiple health conditions likely contributing to this. he arrested at home and CPR was attempted and unsuccessful. Pt received his Covid vaccine #1 on 1/27/21. No issues were noted after vaccine and was due for his 2nd dose next week. However, we were notified he passed away on 2/9/21. Very likely death not at all related to vaccine but wanted to document as patient was in the middle of the covid vaccine series.

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