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From the 11/19/2021 release of VAERS data:

This is VAERS ID 961741

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Case Details

VAERS ID: 961741 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-20
Onset:2021-01-20
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNKNOWN / 1 - / IM
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK UN / -

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, 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), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: copd/chf/sleep apnea/afib/lymphoma
Preexisting Conditions: as above
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient received his vaccine in the. morning of 1/20/2021, while getting into car to go see his pulmonologist, about 2 hours after, collapsed, unresponsive with asystolic cardiac arrest. No symptoms prior other than chronic dyspnea. No allergic type symptoms reported by family. Asystole with EMS, no response to ACLS, presented to ED, DOA.


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