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

This is VAERS ID 413092



Case Details

VAERS ID: 413092 (history)  
Form: Version 1.0  
Age: 9.0  
Sex: Female  
Location: Nevada  
Vaccinated:2010-12-17
Onset:2010-12-18
   Days after vaccination:1
Submitted: 2010-12-18
   Days after onset:0
Entered: 2010-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR 713639DA / UNK LA / IM

Administered by: Other       Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Respiratory arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2010-12-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown manufacturer, report completed by ED doctor. Detailed vaccine information unavailable. Please contact family
Current Illness: uk
Preexisting Conditions: Sickle Cell
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: respiratory and cardiac arrest resulting in death


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=413092

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