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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1049389

Case Details

VAERS ID: 1049389 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Idaho  
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   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: Spironolactone, Atorvastatin, Gabapentin, Trelegy Ellipta, Januvia, Xarelto, Losartan, Metoprolol Succinate.
Current Illness: No
Preexisting Conditions: Type 2 DM, HTN, COPD, Hyperlipidemia unspecified, A-fib unspecified, Chronic pain, Morbid Obesity
Allergies: No
Diagnostic Lab Data: Nothing wife opted out for any test to be performed.
CDC Split Type:

Write-up: Patient passed away Saturday at 14:04pm. Patient''s wife reports his death was sudden, he passed away sitting in his chair his heart just stopped she said. They tried to perform CPR, 911 was called and paramedics arrived at the scene and he was given medication but never had any return of vital signs and so his death was called at the scene. Wife reports he was not ill, did not have any symptoms prior to the event. They are not going to be doing a autopsy. She wanted us to know based on timing that there may be some possible correlation with his COVID19 vaccine. He obtained the vaccine on 02/09/2021 - wife reports he had no symptoms, not even arm soreness after the vaccine. Had no fever, shortness of breath. Did not complain of chest pain. We can update chart to reflect the patient is deceased and lets make a card for the family.

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