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From the 10/15/2021 release of VAERS data:

This is VAERS ID 945603



Case Details

VAERS ID: 945603 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-01-02
Onset:2021-01-08
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0412 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac pacemaker evaluation, Cyanosis, Metabolic function test, Pulse absent
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   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: Verapamil ER, Pepcid, Norco, Vit D3, synthroid, flecainide Ace acetate, mucinex, lisinpril, amitriptyline, eliquis, atorvastatin, furosemide, acetaminophen, Coenzyme Q-10, metoprolol succinate ER
Current Illness: Hospitalized for abnormal heart rhythm 12/18/20.
Preexisting Conditions: anemia, hypothyroidism, BPH, paroxysmal atrial fib, HTN, atherosclerotic heart disease, Chronic Kidney dz stage 3, CHF
Allergies: NKA
Diagnostic Lab Data: 1/5/21 BMP drawn
CDC Split Type:

Write-up: Had no immediate issues with the vaccine. He had returned from the hospital on 12/21 and had some concerns about his weight which were shared with his physician on 1/4/21. On 1/5/21 had a visit with his cardiologist for a pacemaker check. On 1/8/21 staff were called to his room, he was on the floor, bluish skin color. No vital signs found, no heart rhythm heard at 2200.


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