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From the 1/14/2022 release of VAERS data:

This is VAERS ID 455522

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Case Details

VAERS ID: 455522 (history)  
Form: Version 1.0  
Age: 67.0  
Sex: Male  
Location: Ohio  
   Days after vaccination:7
Submitted: 2012-05-14
   Days after onset:67
Entered: 2012-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: Private
Symptoms: Cyanosis, Death, Endotracheal intubation, Fall, Intensive care, Nervous system disorder, Pulse absent, Resuscitation, Ventricular tachycardia
SMQs:, Torsade de pointes/QT prolongation (narrow), Anaphylactic reaction (broad), Angioedema (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Acute central respiratory depression (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2012-03-11
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, ECBASA, Diltiazem CD, HCTZ, albuterol
Current Illness:
Preexisting Conditions: Hypertension, IHSS, Bradycardia, Hypercholesterolemia, Allergic Rhinitis, Asthma
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt returned from arduous bike ride, took long time in bathroom, wife entered, pt started to speak, turned blue and fell to floor. CPR attempted, EMS took to ER where pulseless. Ventricular tachycardia found. Intubated, CCU care, minimal brain activity, died on 4th day.

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