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

This is VAERS ID 1118968



Case Details

VAERS ID: 1118968 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-21
Onset:2021-02-01
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death
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: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away due to cardiac arrest Narrative: The patient had with PMH of CAD and multiple PCI, HFpEF, HTN. DM2, ESRD on HD, COPD and home O2 and other co-morbidities. Patient received his first dose of Pfizer vaccine on 1/21 and no adverse reaction was reported. Patient had a cardiac arrest on 2/1 and he was admitted to hospital. Patient passed away naturally on 2/1. Cause of death is not related to COVID 19 vaccination.


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