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From the 1/7/2022 release of VAERS data:

This is VAERS ID 1339538

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Case Details

VAERS ID: 1339538 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-05-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Cardio-respiratory arrest
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), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-17
   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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Abdominal aortic aneurysm; Myocardial infarction old; Rectal cancer; Surgery
Diagnostic Lab Data:
CDC Split Type: JPPFIZER INC2021570910

Write-up: Cardio-respiratory arrest; This is a spontaneous report from a contactable physician received from the Regulatory Authority. The regulatory authority report number is v21107238. A 73-year and 7-month-old male patient received BNT162B2 (COMIRNATY), via an unspecified route of administration on 16May2021 at 14:00 (at the age of 73-years-old) as a single dose for COVID-19 immunisation. Medical history included abdominal aortic aneurysm, non-ongoing myocardial infarction old on an unspecified date, and status post surgery for rectal cancer (non-ongoing surgery on an unspecified date). The patient''s concomitant medications were not reported. The patient experienced cardio-respiratory arrest on 17May2021 at 07:50 (17 hours and 50 minutes after the vaccination), which was reported as fatal. The clinical course was reported as follows: The body temperature before vaccination was not provided. On 16May2021 (the day of vaccination), and on 17May2021, at 05:00 (15 hours after the vaccination), no particular abnormalities were observed. At 07:50 on 17May2021 (17 hours and 50 minutes after vaccination), when a staff member visited the patient''s room the next time, she had been already in cardio-respiratory arrest. The patient died on 17May2021. The cause of death was reported as cardio-respiratory arrest. It was not reported if an autopsy was performed. The reporting physician assessed that the causality between the event and BNT162B2 as unassessable (reported as unknown). Other possible causes of the event, such as any other diseases, was reported as unknown. The lot number for the vaccine, BNT162B2, was not provided and will be requested during follow up.; Reported Cause(s) of Death: Cardio-respiratory arrest

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