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

This is VAERS ID 435354

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Case Details

VAERS ID: 435354 (history)  
Form: Version 1.0  
Age: 54.0  
Sex: Male  
Location: Wisconsin  
   Days after vaccination:7
Submitted: 2011-09-23
   Days after onset:16
Entered: 2011-09-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Private
Symptoms: Autopsy, Death, Livedo reticularis, Peripheral coldness, Pulse absent, Respiratory arrest, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-09-07
   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: none
Current Illness: no c/o illness by patient
Preexisting Conditions: Hypertension Type 1 diabetes
Diagnostic Lab Data: I dont have results of postmortum as of today. Still pending.
CDC Split Type:

Write-up: At 12:30 PM patient laid down for a nap he offered no co at that time, at 2 PM I (wife) found patient unresponsive no pulse no respiratory effort. His skin was cold and moteled I dailed 911 and began chest compressions as instructed by 911 operator. I never got a pulse first responders and also worked on patient and transfered him to hospital he was pronounced dead at 2:08 pm on 09/07/2011.

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