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From the 5/14/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1084203

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Case Details

VAERS ID: 1084203 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-02-24
Onset:2021-03-08
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNK / 1 UN / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNK / UNK UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Apnoeic attack, Dyspnoea, Endotracheal intubation, Heart rate irregular, Heart rate normal, Mechanical ventilation, Pulse absent, Resuscitation
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations: Cardiac Arrest
Other Medications: unk
Current Illness: unk
Preexisting Conditions: unk
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was visiting dr for routine checkup. Pt began to experience difficulty breathing, 911 called. I showed up to pt apneic, pulseless. CPR initiated. Return of spontaneous circulation in ambulance (without Rx). Pt intubated, ventilations continued throughout contact. Pt still had spontaneous pulse upon delivery ti ED, placed on vent in our presence. Pt later transported to Level 1 hospital on vent.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210514&IDNUMBER=1084203


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