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From the 11/12/2021 release of VAERS data:

This is VAERS ID 1380360

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Case Details

VAERS ID: 1380360 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Cardio-respiratory arrest
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), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-27
   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:
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data:
CDC Split Type: JPPFIZER INC2021622824

Write-up: Cardio-respiratory arrest; This is a spontaneous report from a contactable physician received from the Agency Regulatory Authority. The regulatory authority report number is v21110139. A 73-year and 4-month old male patient received BNT162B2 (COMIRNATY), via an unspecified route of administration, on 25May2021 (at the age of 73-years-old) as a single dose for COVID-19 immunisation. The patient''s medical history and concomitant medications were not reported. The patient experienced cardio-respiratory arrest on 27May2021 at 19:30 (2 days, 19 hours, and 30 minutes after the vaccination), which was reported as fatal. The course of the event was as follows: On 25May2021 (the day of vaccination), the patient received a dose of BNT162B2 vaccination. On 26May2021 (one day after vaccination), the patient underwent dialysis at his primary hospital. On 27May2021, at 10:00 (2 days and 10 hours after vaccination), the patient was finally confirmed to be healthy. At 18:55 (2 day, 18 hours, and 55 minutes after vaccination; as reported), when the patient''s family member visited the patient''s room, the patient was found to have cardio-respiratory arrest on the futon (thick bedquilt). At 19:15 (2 days, 19 hours, and 15 minutes after vaccination), the patient was transferred to the reporting hospital; however, resuscitation could not be performed, and she was confirmed to die at 19:30 (2 days, 19 hours, and 30 minutes after vaccination). The patient died on 27May2021 at 19:30. The cause of death was reported as cardio-respiratory arrest. It was not reported if an autopsy was performed. The reporting physician assessed that the causality between the event and BNT162B2 as unassessable. There was no other possible cause of the event such as any other diseases.; Reported Cause(s) of Death: Cardio-respiratory arrest

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