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

This is VAERS ID 961434

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Case Details

VAERS ID: 961434 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Ohio  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Echocardiogram abnormal, Musculoskeletal stiffness, Pulseless electrical activity, Pupil fixed, Resuscitation
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), Dystonia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Arthritis (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tamsulosin 0.4 mg daily Metoprolol Succinate ER 100 mg daily Rivaroxaban 15 mg daily Levothyroxine 100 mcg daily Furosemide 40 mg daily Atorvastatin 40 mg daily Amiodarone 200 mg daily Nitroglycerin 0.4 mg SL PRN Aspirin 81 mg daily Polyeth
Current Illness: Chronic back pain
Preexisting Conditions: Cardiovascular LBBB (left bundle branch block) HTN (hypertension) Pure hypercholesterolemia CAD (coronary artery disease) Acute systolic heart failure (HCC) Atrial fibrillation (HCC) Nephrology Stage 3 chronic kidney disease Endocrinology Controlled type 2 diabetes mellitus with microalbuminuria, without long-term current use of insulin (HCC) Amiodarone-induced thyroiditis Other BPH (benign prostatic hyperplasia)
Allergies: No know allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: This is a 94-year-old male who is brought in by ambulance after being found on the floor with unknown downtime. He was in asystole upon EMS arrival. He remains in asystole. No advanced airway is in place. The patient is getting compressions from Lucas device upon arrival. It was reported that he was last talked to by family at 2 PM. The patient got his SARS-CoV-2 vaccination this morning. The patient is evaluated emergently. CPR was ongoing with 3 rounds of epinephrine given. The patient remains in asystole. He has rigor mortis. The patient''s pupils are fixed and dilated. The patient has compressions paused and ultrasound is used to evaluate for cardiac activity. None is detected. The patient has no electrical activity on monitor. The patient''s time of death is 2113.

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