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

This is VAERS ID 1028101



Case Details

VAERS ID: 1028101 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-01-22
Onset:2021-01-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood gases abnormal, Cardio-respiratory arrest, Death, Electrocardiogram abnormal, Hypoxia, Metabolic acidosis, Metabolic function test normal, Myocardial ischaemia, Pain in extremity, Peripheral swelling, Pulmonary embolism, Pulseless electrical activity, Resuscitation, SARS-CoV-2 test negative, Syncope, Troponin normal
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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: Allopurinol 400mg Daily
Current Illness: Hyperuricemia Renal stone
Preexisting Conditions: Hyperuricemia Renal Stones
Allergies: Shellfish
Diagnostic Lab Data: ABG'' Met acidosis hypoxia EKG; Inf ischemia BMP; normal Troponin; Normal Covi 19 ;Neg
CDC Split Type:

Write-up: Pt develops left leg pain The day after vaccination in AM subsequently drove approximately 150 miles On his way back stopped at his brothers place for lunch. He then collapsed coning down the steps, EMS started CPR. took him to ER Resuscitated briefly but went into CardioPulm Arrest again and PEA Resucitaion for aprox 1 hour but was unsuccessful. Noted to have Left leg more swollen than Right by 3 to 4 CM presumed to have died from massive Pulmonary embolism and inferior wall myocardial ischemia


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