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

This is VAERS ID 1032161



Case Details

VAERS ID: 1032161 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: New Hampshire  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Blood pressure decreased, Death, Decreased appetite, Fall, Food refusal, Lip blister, Oral mucosal blistering, Weight decreased
SMQs:, Severe cutaneous adverse reactions (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Shingles - Glaxo 8/22/2020, resulted in hospitalization and LTC.
Other Medications: Vitamin D, Methotrexate
Current Illness: Dementia, Arthritis
Preexisting Conditions: Dementia, Arthritis
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: The day after the 2nd shot, patient developed blisters on his lips and mouth. The care facility said that he had a nut allergy -- but he had never been allergic to nuts. He stopped eating and drinking and his BP had dropped to 60/40. By Jan 16th they called to say he was dying and he passed away on 1/18/21. Patient had COVID19 from Oct 29th - early November. By Nov 21st he had lost 40 lbs. He was 6''3" and had gone from 189lbs to 149 lbs with COVID. By Nov 21st when we could visit, he had recovered from COVID, but was very thin and weak. He could not bathroom alone and kept falling. He didn''t seem to have a bad reaction to the 1st COVID shot, But he immediately reacted to the 2nd shot and passed away within 6 days.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1032161


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