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

This is VAERS ID 1031595



Case Details

VAERS ID: 1031595 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2020-12-29
Onset:2021-02-05
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood pressure increased, COVID-19, Heart rate increased, Renal failure, SARS-CoV-2 test positive, Unresponsive to stimuli
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lasix, Digoxin, Eliquis, Metoprolol, Celexa, Plavix, Namenda
Current Illness: Covid + 1/6/2021
Preexisting Conditions: CHF, Heart Disease, Dementia, A Flutter HTN
Allergies: NKDA
Diagnostic Lab Data: Resident was sent to hospital for further evaluation. Medical records not available to this facility since resident did not return to us.
CDC Split Type:

Write-up: Unresponsive, Increase BP and H. Hospital Dx Renal Failure


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1031595


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