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From the 9/17/2021 release of VAERS data:

This is VAERS ID 27275

Case Details

VAERS ID: 27275 (history)  
Form: Version 1.0  
Age: 82.0  
Sex: Male  
Location: Minnesota  
   Days after vaccination:0
Submitted: 1990-12-26
   Days after onset:30
Entered: 1991-01-02
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Other
Symptoms: Apnoea, Cardiac 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 (narrow), Cardiomyopathy (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1990-11-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Ascriptin, Metamucil
Current Illness:
Preexisting Conditions: No allergies, murmur, parkinson''s dsiease, arthritis, early cataracts, excision sebaceous cyst of back, benign keratosis of face.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt vaccinated with FLUOGEN apparent cardiac arrest - no breath/pulse 8PM - CPR initiated - transported to hosp where he expired.

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