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

This is VAERS ID 1031780



Case Details

VAERS ID: 1031780 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-23
Onset:2021-02-01
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Oxygen saturation decreased, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Reported chronic lung disease. Additional details are unknown.
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient was not seen at our facilities prior to or after COVID-19 vaccination. Patient received first dose on 1/23/2021 and as reported by the family member, patient expired on 2/5/21. Symptoms were reported to have stared on 2/1/2021, 9 days after receiving the first dose with a drop in oxygen levels and fever. He was reported to also have a history of chronic lung disease. Patient''s family member to be contacted if necessary.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1031780


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