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

This is VAERS ID 1029744



Case Details

VAERS ID: 1029744 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-01-18
Onset:2021-01-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiomegaly, Chest X-ray abnormal, Chills, Death, Eosinophil count increased, Full blood count, Immediate post-injection reaction, Metabolic function test normal, Oedema peripheral, Pain, Peripheral swelling, SARS-CoV-2 test negative
SMQs:, Cardiac failure (broad), Angioedema (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 26
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: tamsulosin, simvastatin, aspirin, doxazosin, colace, loratadine, vitamin b12, senna, vitamin b complex, omeprazole, alendronate, vitamin d3, calcium
Current Illness: none
Preexisting Conditions: hyperlipidemia, hypertension, digenerative disc disease, BPH, osteoporosis, skin cancers- removed, constipation, allergic rhinitis
Allergies: chlorpheniramine
Diagnostic Lab Data: covid swab neg, CBC with elevation eosinophils, CMP stable, chest xray with cardiomegaly no other acute findings 2/4/2021
CDC Split Type:

Write-up: right arm swelling immediately after injection. followed by bilateral lower leg edema, chills and body aches that continued daily at 2 weeks post immunization admin 2/4/21 treated with dexamethasone 6mg PO x 7 days- this resolved his s/s 2/13/21 patient passed away at facility


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1029744


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