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From the 1/22/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 960841

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Case Details

VAERS ID: 960841 (history)  
Form: Version 2.0  
Age: 23.0  
Sex: Male  
Location: New York  
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Chest X-ray abnormal, Death, Lung infiltration, Pyrexia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (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), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amantadine, clonazepam, clobazam, lovenox, dextroamphetamine-amphetamine , famotidine, gabapentin, keppra, robinul, polyethylene glycol, propanolol, sertaline, senna, valproic acid, vimpat, cefepime
Current Illness: none
Preexisting Conditions: ventilator dependent, anoxic encephalopathy, seizure disorder
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient developed 104.4 temp approximately 48 hours after being given the vaccine. I treated him with antibiotics, IV fluids, cooling methods. CXR does show a new right perihilar infiltrate. However, his fever came down within the next 24-48 hours. Unfortunately, he suffered a cardiac arrest on 1/21/21 in the early morning and expired.

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