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From the 4/30/2021 release of VAERS data:

This is VAERS ID 844189



Case Details

VAERS ID: 844189 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2019-10-29
Onset:2019-10-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2019-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE) / SANOFI PASTEUR UJ288AB / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Aspiration, Cyanosis, Death, Pulse absent, Resuscitation, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2019-10-29
   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: Levemir, Pravastatin, Furosemide, Lisinopril, Latanoprost
Current Illness: Diabetes, COPD
Preexisting Conditions: Diabetes, COPD
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient Fainted when he got to his cart. Pharmacist rushed to his side. He was already blue, and pharmacist could not feel a pulse. Patient was moved quickly to start CPR. CPR was started and patient was aspirating. Mouth and nose were cleared out. CPR was continued. Patient was aspirating and breaths could not me administered. CPR was continued until EMT arrived. EMT continued CPR. Patient was not responsive. EMT called time of death.


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