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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1016222



Case Details

VAERS ID: 1016222 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-21
Onset:2021-01-25
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9262 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaemia, Angina pectoris, Blood test abnormal, Death, Dyspnoea, Electrocardiogram, Injection site pain, Resuscitation, Syncope, Transfusion
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Coreg, Ranexa, Bayer low dose Aspirin, Brilinta, Tums, Pantoprazole, Nitro 0.4mg sq prn, Imdur, Rosuvastatin, Glimiperide, Sucralfate
Current Illness: 3 weeks prior to immunzation hospitalized for one day due to symptomatic anemia and got a blood transfusion
Preexisting Conditions: Hypertension, CAD s/p cabg 1996 s/p multiple stents last 2013, history of stroke 1996, high cholesterol, diabetes type 2, iron deficiency anemia
Allergies: Contrast dye, lisinopril
Diagnostic Lab Data: No labs or tests were done, she was transported to hospital for further resuscitation measures but not successful.
CDC Split Type:

Write-up: My mom only had site soreness after her covid vaccine on 1/21 which resolved within a couple days. However, she died in the early morning hours of 1/25, she was fine the day before, no sign of injury. We found her collapsed on the ground and although we tried cpr she was already dead. She had gone to the hospital on 12/28 for shortness of breath, angina and symptomatic anemia, her ekg was unchanged and blood work normal except for anemia. The cardiologist did not think a cardiac cath was needed. Her shortness of breath improved with a blood transfusion and a dose of lasix (no heart failure).


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1016222

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