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

This is VAERS ID 1050128

Case Details

VAERS ID: 1050128 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: West Virginia  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Cardiac arrest, Death, Dyspnoea, Fatigue, Gait disturbance, Loss of consciousness, Respiratory arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2014-02-14
   Days after onset: 2550
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Eliquis 5MG, Carvedilol 6.25MG, Ramipril 2.5 MG, Atorvastatin 80 MG 1 tab daily ,Stiolto Respimat Inhalation spray 2 puffs per day; Albuterol Sulfate Inhaler as needed, Ipratropium Bromide 0.5 mg and Albertol Sulfate0.3mg inhalation soluti
Current Illness: none
Preexisting Conditions: 1.COPD started in 2008 from a Neurosurgery and had to be on a ventalator: 2 Open Heart Surgery Had a pacemaker
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: 02/07/21 through 2/13/21 slightly fatiqued, took all his prescribed medications, ate breakfast, lunch and dinner was drinking eight 10 oz bottles of water. On 02/14/21 was very tired had a difficult time breathing after taking the normal meds. He took a breathing treatment with his prescribed Ipratropium Bromide and Albuterol Sulfate via home nebulizer. This did not improve his breathing. He was very weak and breathing was labored. 911 was called by wife. 911EMTchecked pulse and breathing. Informed him they would give him a breathing treatment.He started to go limp. EMT''s got him to Ambulance and to Medical Center to the ER. Heroics done. He died. Pulmonary and Cardiac Arrest

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