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From the 5/7/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 936170

Case Details

VAERS ID: 936170 (history)  
Form: Version 2.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Circulatory collapse, Death, Myocardial infarction
SMQs:, Anaphylactic reaction (narrow), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Embolic and thrombotic events, arterial (narrow), Hypersensitivity (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   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: ; ; BETNOVATE; ; ; ; ; ; ;
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Acute myocardial infarction; Basal cell carcinoma; Cataract; Chronic kidney disease; Colitis ischaemic; Debridement (Arthroscopic debridement of patella); Essential hypertension; Mitral valve incompetence; Myocardial ischaemia; Neoplasm malignant (other/unspecified site); Transurethral bladder resection; Comments: Patient has not had symptoms associated with COVID-19. Patient has not been tested/or has had an inconclusive test for COVID-19. Patient is not enrolled in clinical trial.
Diagnostic Lab Data:
CDC Split Type: GBPFIZER INC2021012711

Write-up: Myocardial infarct; Circulatory collapse; This is a spontaneous report from a contactable physician from the regulatory authroity. The regulatory authority report number is GB-MHRA-ADR 24553112 and GB-MHRA-WEBCOVID-20210104143047. An 82-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE; Lot number: EJ1688), via an unspecified route of administration, on 31Dec2020 at a single dose for COVID-19 vaccination. Medical history included mitral valve incompetence from 08May2020, myocardial ischaemia from 07May2020, acute myocardial infarction from 07May2020, cataract from 29Nov2019, chronic kidney disease from 03Oct2013, colitis ischaemic from 23May2013, basal cell carcinoma from 20Apr2012, transurethral bladder resection on 06Sep2005, neoplasm malignant (other/unspecified site) from 16Aug2005, debridement (arthroscopic debridement of patella) on 12Jan2005, and essential hypertension from 2005. The patient had not had symptoms associated with COVID-19. The patient was not been tested/or had an inconclusive test for COVID-19. The patient was not enrolled in clinical trial. Concomitant medications included allopurinol (MANUFACTURER UNKNOWN), atorvastatin (MANUFACTURER UNKNOWN), betamethasone valerate (BETNOVATE), bisoprolol (MANUFACTURER UNKNOWN), furosemide (MANUFACTURER UNKNOWN), glyceryl trinitrate (MANUFACTURER UNKNOWN), loperamide (MANUFACTURER UNKNOWN), omeprazole (MANUFACTURER UNKNOWN), phenoxymethylpenicillin (MANUFACTURER UNKNOWN), and ramipril (MANUFACTURER UNKNOWN). The patient experienced myocardial infarct and circulatory collapse on 31Dec2020. The event, myocardial infarct, was reported as fatal. It was reported that the patient collapsed at home the evening after vaccination. The clinical outcome of myocardial infarct was fatal and of circulatory collapse was not recovered. The patient died on 31Dec2020. The cause of death was reported as myocardial infarct. It was unknown if an autopsy was performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: Myocardial infarct

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