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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 1273868

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Case Details

VAERS ID: 1273868 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-26
Onset:2021-04-28
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 AR / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Malaise, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-28
   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: Hydrochlorothiazide, Amlodipine, Coreg, Benazepril, Lipitor, Amaryl, Actos, Metformin, Tylenol #3
Current Illness: None. Reports to neighbor of "feeling under the weather" sometime about 04/24/2021 to 4/27/2021.
Preexisting Conditions: Type 2 DM with retinopathy and neuropathy, HTN, BPH, DDD lumbar spine
Allergies: Ambien, Ativan, Cardura, Elavil, Darvocet (?)
Diagnostic Lab Data: Check with local Medical Examiner
CDC Split Type:

Write-up: Sudden death (Patient''s son should have access to COVID-19 vaccination card with lot numbers and location where vaccine was administered.)


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