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From the 4/30/2021 release of VAERS data:

This is VAERS ID 1124794

Case Details

VAERS ID: 1124794 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Male  
Location: New York  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Chest pain, Death, Headache, Pyrexia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? Yes
Died? Yes
   Date died: 2021-03-20
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Ipratropium Bromide, (0.5mg/2.5ml) (Atrovent) Budesonide, (0.5mg/2ml) (Pulmicort) Tobi neb, (28 days on/28 Days off) Glycopyrolate, (2mg) (Robinol) Aspirin, (81 mg) Omeprazole, (20 mg) (Prilosec) Cimetidine, (300 mg) Azithromycin, (250
Current Illness: Pulmonary inflammation
Preexisting Conditions: MEDICAL SUMMARY: VATER?S SYNDROME ? Tetralogy of Fallot with LPA Atresia s/p repair (last conduit replacement 2/96) ? TE Fistula s/p repair 10/89 (Medical Center) ? Abnormal Ear Canals ? Absent right kidney ? Absent Corpus Colossus ? Abnormal Vertebrae (fissured) ? 7th Nerve Palsy ? Developmental Delays ? Nissen Fundoplication 11/89 (AMC), failed ? G-Tube placement 9/89 (AMC) ? J-Tube placement 3/95 (BCH) (complicated with fistulas) ? ? CVA 0-3mo. ? Reglan Reaction 12/90 (fever - 108.1F) ? Upper Right Lobectomy 10/93 (BCH) ? Poor Venous Access ? Seizure Disorder, controlled, out grown ? Growth on back of tongue (looks like ordinary tissue-benign-prone to bleeding if irritated) ? Enlarged Adenoids ? 6th digit left hand (ligated 9/89) ? Prone to Candida ? Pseudomonas Picetti lung infection 2/98, colonized ? History of bleeding duodenal ulcer ? MRSA 05/07, lungs, colonized ? Power Port placed 2/15 ? Power Port removed due to bacterial infection 6/15 ? Cardiac Cath, LPA Stent dilated, 20mm/100%, Melody valve placed, RV, 8/27/2015, (BCH)
Allergies: Medication Allergies: REGLAN, Morphine, Droperidol, Intal, Keflex, Erythromycin, Augmentin, Latex FOOD ALLERGIES: Milk, NUTS ENVIRONMENTAL ALLERGIES: Evergreens, Dust, Mold, Dog and Cat dander, Spiders, ?Bugs?
Diagnostic Lab Data: none known
CDC Split Type:

Write-up: Extreme head ache, chest pain, fever 101 F. Gave 1000 mg Tylenol, albuterol via nebulizer Q4hr. Died 3/20/2021 approx 11:00 am from Cardiac Arrest.

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