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From the 6/4/2021 release of VAERS data:

This is VAERS ID 38816

Case Details

VAERS ID: 38816 (history)  
Form: Version 1.0  
Age: 81.0  
Sex: Male  
Location: Nevada  
   Days after vaccination:22
Submitted: 1992-01-07
   Days after onset:20
Entered: 1992-01-15
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Public
Symptoms: Apnoea, Cardiac arrest, Myalgia
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (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), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1991-12-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: UNK~ ()~~~In patient
Other Medications: Home 02 therapy; voltaren 75 mg BID;
Current Illness: COPD
Preexisting Conditions: CHF, COPD
Diagnostic Lab Data: NONE
CDC Split Type: NV92001

Write-up: C/o muscular ache 2 days p/immun relieved of aches p/5 days; no c/o of other rxn when followed-up on 2DEC91; cardio-pulmonary arrest 18DEC91 @ 120PM; death certificate not available for review, as yet;

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