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

This is VAERS ID 1112894

Case Details

VAERS ID: 1112894 (history)  
Form: Version 2.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Pulmonary embolism
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), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Bechterew''s disease; Parkinson''s disease
Preexisting Conditions: Medical History/Concurrent Conditions: Ankylosing spondylitis; Shoulder operation NOS (2 shoulder surgeries in November 2020)
Diagnostic Lab Data:
CDC Split Type: DEPFIZER INC2021266927

Write-up: Cardiac arrest; pulmonary embolism; This is a spontaneous report downloaded from the regulatory authority. The Regulatory authority report number is DE-PEI-CADR2021015340. A non-contactable consumer reported that an 82-years-old male patient received BNT162B2 (COMIRNATY, Solution for injection, Lot number and Expiry dates were not reported), via intramuscular route of administration, on 23Jan2021, as single dose for COVID-19 immunisation. Medical history included shoulder operation NOS in Nov2020 (2 shoulder surgeries in November 2020), ongoing parkinson''s disease, ongoing Bechterew''s disease and ankylosing spondylitis. The patient''s concomitant medications were not reported. On 23Jan2021 patient experienced cardiac arrest, pulmonary embolism. The outcome of the cardiac arrest was fatal and for pulmonary embolism outcome was unknown. The patient died on an unspecified date in 2021 due to cardiac arrest. It was not reported if an autopsy was performed. Causality: Inconsistent causal association to immunization for both events. Sender Comment: Parkinson''s disease, ankylosing spondylitis, 2 shoulder surgeries in November 2020/ cardiac arrest diagnosis pulmonary embolism Follow-up activities closed: downloaded from database.; Reported Cause(s) of Death: Cardiac arrest

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