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

This is VAERS ID 1180245



Case Details

VAERS ID: 1180245 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-10
Onset:2021-03-26
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6205 / 2 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Echocardiogram abnormal, Endotracheal intubation, Resuscitation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   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: Hyperlipidemia; htn; diabetes,
Allergies: NKA
Diagnostic Lab Data: Patient was helping to place lines on the football field when he had a sudden witnessed collapse, CPR was initiated and EMS was involved. Intubated in field with CPR following ACLS protocol during transport to ER. Asystole, confirmed in 2 leads and bedside echo showed no cardiac activity.
CDC Split Type:

Write-up: Death within 30 days of vaccination


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1180245

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