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

This is VAERS ID 1230054

Case Details

VAERS ID: 1230054 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Texas  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Cardiac arrest, Death, Mechanical ventilation, Mental status changes, SARS-CoV-2 test positive, Shock, Urinary tract infection enterococcal, Urinary tract infection pseudomonal
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), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol/Ipratropium nebulizations prn, Amoxicillin 875 mg
Current Illness:
Preexisting Conditions: Anxiety, Bladder cancer s/p transurethreal resection 9/2019, Coronary Artery Disease s/p PCI to RCA, Chronic Back pain
Allergies: Levodopa (muscle jerking), Empagliflozin (Dehydration), cont.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pfizer COVID-19 Vaccine EUA Patient received vaccine dose #1 on 1/14/2021 and Dose #2 on 1/31/2021. Patient presented to ED on 2/1/2021 with complaints of acute mental status change. He was recently diagnosed with enterocoal/pseudomonas UTI four days prior to presenting to ED and was being treated with Augmentin and Levaquin. Patient screened positive for COVID-19, with the sample analyzed using PCR or equivalent. Patient suffered a cardiac arrest on 2/7/2021 x3, developed three pressor shock, and required maximum ventilator settings. Patient subsequently expired.

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