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From the 5/7/2021 release of VAERS data:

This is VAERS ID 1123329



Case Details

VAERS ID: 1123329 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-21
Onset:2021-03-22
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6204 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Dyspepsia, Influenza virus test negative, Pulseless electrical activity, Respiration abnormal, Respiratory arrest, Respiratory syncytial virus test negative, SARS-CoV-2 test negative
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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific dysfunction (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypersensitivity (broad), Respiratory failure (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-22
   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: unknown
Current Illness: unknown
Preexisting Conditions: Aortic stenosis, DM2, COPD, HTN, CAD
Allergies: unknown
Diagnostic Lab Data: COVID negative, Flu Negative, RSV negative
CDC Split Type:

Write-up: Presented to Emergency department in cardiac arrest. Pt''s family reports patient complaining of indigestion throughout the night. Awakened this morning but returned to bed. Family noted his breathing became loud and then stopped. EMS called. Patient in PEA arrest when they arrived. Patient''s family reports he received COVID-19 vaccine day before via facility. I have notified the vaccine clinic and received the Lot number of the vaccine use when I called.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1123329


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