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From the 5/14/2021 release of VAERS data (an older release, current is 11/19/2021):

This is VAERS ID 1054175

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Case Details

VAERS ID: 1054175 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Virginia  
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   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: Plavix, allopurinol, amlodipine, aspirin, Colace, donepezil, finasteride, losartan potassium, oxybutynin, polyethylene glycol, rosuvastatin, vitamin d, Tamsulosin,
Current Illness: Acute Kidney Failure
Preexisting Conditions: Cognitive communication deficit, dysphagia, gout, hyperlipidemia, other abnormalities of gait and mobility, personal history of TI and cerebral infarction without residual deficits, unspecified osteoarthritis, benign prostatic hyperplasia with lower urinary tract symptoms, constipation, essential hypertension, history of falling, obstructive and reflux uropathy, overactive bladder, unspecified dementia without behavioral disturbance.
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident found unresponsive, CPR initiated and EMS called. EMS called time of death after arrival.

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