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From the 3/11/2021 release of VAERS data (an older release, current is 11/19/2021):

This is VAERS ID 1081308

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Case Details

VAERS ID: 1081308 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-02
Onset:2021-03-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6198 / 2 AR / SYR

Administered by: Public       Purchased by: ?
Symptoms: Cardiac arrest, Death, Laboratory test normal
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: none
Preexisting Conditions: none
Allergies: N/A
Diagnostic Lab Data: Multiple Cardiac tests were done at ER, all were returned normal. Went into Cardiac arrest and was unable to resuscitate.
CDC Split Type:

Write-up: Death 3 days afterards, undetermined cause at this time.


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