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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1082985



Case Details

VAERS ID: 1082985 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-25
Onset:2021-02-28
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6202 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Dyspnoea, Eye movement disorder, Foaming at mouth, Grunting, 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), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Ocular motility disorders (narrow), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   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: LISINOPRIL 5MG TAB TAKE ONE TABLET BY MOUTH ONCE DAILY PREDNISONE 5MG TAB TAKE THREE TABLETS BY MOUTH EVERY MORNING TERAZOSIN HCL 10MG CAP TAKE ONE CAPSULE BY MOUTH AT BEDTIME FOR PROSTATE
Current Illness: Worsened dyspnea x 1.5 to 2 weeks prior.
Preexisting Conditions: Polymyalgia rheumatica, on prednisone; diagnosed 9/2020.
Allergies: Levothyroxine (lower extremity edema)
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient had been feeling dyspneic for 1.5 weeks to 1 month prior to his death on 2/28/21. He received vaccine on 2/25/21. On his family found him leaning on the couch with eyes rolled back and foaming at the mouth. He was making noises (like grunting sounds?). EMS was called. He had cardiac arrest while in ambulance enroute to EMS. Resuscitation efforts continued in ED. Family was informed about his status and resuscitation efforts were stopped.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1082985

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