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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1380183

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Case Details

VAERS ID: 1380183 (history)  
Form: Version 2.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Respiratory disorder
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Diabetes; Drug allergy; Glaucoma; Hypertensive heart disease
Diagnostic Lab Data:
CDC Split Type: ITPFIZER INC2021590996

Write-up: cardio-circulatory arrest; respiratory deficit; This is a spontaneous report from a contactable physician downloaded from a regulatory authority-WEB, regulatory authority number IT-MINISAL02-731613. An 86-year-old male patient received the 2nd dose of BNT162b2 (COMIRNATY, Batch: EY7056, Expiry Date: 31Aug2021) via intramuscular route in the right shoulder on 12May2021 at 12:00 as a single dose for COVID-19 immunization. Medical history included hypertensive heart disease, diabetes, glaucoma and allergy to quinolone antibiotics. Concomitant medications included in home therapy with rosuvastatin (CRESTOR), furosemide (LASIX), metformin, glyceryl trinitrate(VENITRIN), and glicazide (DIAMICRON). The patient previously received the first dose of BNT162b2 on 21Apr2021 (Batch: EW2246, Expiry Date: Jul2021) as a single dose for COVID-19 immunization. On 15May2021 the patient entered the emergency room with respiratory deficit, CPR performed with cardiocirculatory arrest. The outcome of cardiocirculatory arrest was fatal, of respiratory deficit was unknown. The patient died on 15May2021. No autopsy was performed. Sender Comment: RLFV_17/05/21: lot, expiration date, administration 1st dose and any suspected adverse reaction; concomitant. pathologies and drugs, clinical report, possible autopsy. A regulatory authority: 19May20/21: dose, posology, indications of use and duration of therapy concomitant Drugs, clinical report Reporter comment: Patient enters the emergency room with respiratory deficit. Stops circulatory cardio; Reporter''s Comments: Patient enters the emergency room with respiratory deficit. Stops circulatory cardio; Reported Cause(s) of Death: cardio-circulatory arrest

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