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

This is VAERS ID 1169181

Case Details

VAERS ID: 1169181 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Vermont  
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Cyanosis, Death, Discomfort, Hyperhidrosis, Myocardial infarction, Pain in extremity, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   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: Vitamin D3 Sominex Probiotic Ferrous Sulfate 324mg Multivitamin Flomax 0.4mg Ketaconazole Cream PRN Triamcinolone Cream PRN
Current Illness: Quadraparesis due to neuromuscular juctional disorder Neurogenic bladder Hemrrhoids Basal Cell Carcinoma shoulder
Preexisting Conditions: Quadraparesis
Allergies: Sulfa Drug - rash
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Wife reported that no side effects from vaccine noted until 3/16/2021 when patient had arm and back pain and wanted to go back to bed and she noted he was extremely sweaty at that time. He was lifted back to bed and was reportioned several times because he could not get comfortable. She went to get him a drink from the kitchen and heard a guttural sound and rushed back to find him unresponsive and blue in color. She called "911" and patient was dead upon arrival (and a DNR) so the Medical examiner arrived and pronounced him dead. She states sx started at about 4pm and he was pronounced dead at about 5pm. Medical examiner determined a heart attack cause of death. The family not sure that the vaccination had anything to do with death but wanted it to be reported.

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