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From the 6/11/2021 release of VAERS data:

This is VAERS ID 992237



Case Details

VAERS ID: 992237 (history)  
Form: Version 2.0  
Age: 42.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-25
Onset:2021-01-29
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardioversion, Chest discomfort, Death, Dyspepsia, Electrocardiogram, Endotracheal intubation, Mechanical ventilation, Palpitations, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant 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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific dysfunction (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Nebivolol 5mg; Pantoprazole 40 mg; Levocetirizine dehydrochloride 10 mg
Current Illness:
Preexisting Conditions: Hypertension; Hyperlipidemia; decreased GFR. Family history of CAD
Allergies: None
Diagnostic Lab Data: Bag valve mask and intubation prior to arrival to ED. Epi x3 and defibrillation x2.
CDC Split Type:

Write-up: 1/28/2021- Seen by FNP for indigestion, chest pressure and palpitations. EKG reviewed and referral made to Cardiology. 1/29/2021-1800 Presented to ED in cardiac arrest-onset PTA. Patient was found unresponsive by his wife at their home. The last known well was at 1530 when she called him on the phone. The patient was pronounced at ~1850.


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=992237


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