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

This is VAERS ID 29960

Case Details

VAERS ID: 29960 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Maryland  
   Days after vaccination:7
Submitted: 1991-01-14
   Days after onset:97
Entered: 1991-04-18
   Days after submission:93
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Public       Purchased by: Public
Symptoms: Apnoea, Cardiac arrest, Pneumonia
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), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1990-10-09
   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:
Current Illness: pneumonia, chronic bronchitis
Preexisting Conditions: heart disease, chronic renal failure /w ADCVD, nephrosclerotic vasc disease,HTN,pulmonary emphysema, peripheral vasc disease
Diagnostic Lab Data: none
CDC Split Type: MD91019

Write-up: Acute myocardial infarction assoc /w ischemic heart disease. Cardiogenic shock&congestive heart failure due to acute MI.Viral pneumonia assoc /w recent Inflenza vax complicated by 2ndary bacterial pneumonia leading to resp failure..see WORM

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