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

This is VAERS ID 1077297



Case Details

VAERS ID: 1077297 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-03-05
Onset:2021-03-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6205 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Resuscitation, Syncope
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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Plavix. Digoxin. Lasix. Spironolactone. Coq10. Zinc. Vit c. Vitamin d. Multiple vit.
Current Illness: Stable CASHD. stable COPD. No acute illnesses
Preexisting Conditions: CASHD. COPD
Allergies: None
Diagnostic Lab Data: Taken to medical center for resuscitation.
CDC Split Type:

Write-up: He collapsed and went into cardiac arrest


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1077297

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