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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1285361

Case Details

VAERS ID: 1285361 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Texas  
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Cardiac failure, Coxsackie virus test, Coxsackie virus test negative, Death, Endotracheal intubation, Influenza virus test negative, Lung assist device therapy, Myocarditis, SARS-CoV-2 test negative
SMQs:, Cardiac failure (narrow), Angioedema (broad), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-27
   Days after onset: 5
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: Zolpidem Zithromax Crestor Doxycyclin
Current Illness: n/a
Preexisting Conditions: Hyperlipidemia
Allergies: NKDA
Diagnostic Lab Data: Coxsackie B1, B2, B3, B4, B5, and B6 antibodies were all negative. Influenza and Covid testing were both negative.
CDC Split Type:

Write-up: I am unsure if this illness was related to his recent vaccination. However, after seeing reading this article about possible link between covid vaccination and the development of myocarditis, I felt compelled to report: The patient in question is a 53 year old man with a history of previous carotid artery dissection and hyperlipidemia transferred to our hospital from an outside facility for presumed myocarditis. He rapidly decompensated, required intubation, multiple vasopressors, was initiated and ultimately expired.

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