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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1036479

Case Details

VAERS ID: 1036479 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Illinois  
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Abdominal injury, Acute myocardial infarction, Bilevel positive airway pressure, Blood alkaline phosphatase increased, Blood creatinine increased, Blood lactic acid decreased, Blood urea increased, Brain natriuretic peptide increased, Cardiac failure congestive, Chest X-ray abnormal, Chest injury, Computerised tomogram normal, Contusion, Death, Dyspnoea, Fall, General physical health deterioration, Glomerular filtration rate decreased, Hypoxia, Lung opacity, Platelet count decreased, SARS-CoV-2 test negative, Troponin I increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Liver related investigations, signs and symptoms (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Interstitial lung disease (narrow), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), 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: 2021-02-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allegra daily as needed; Ambien 5mg daily at bedtime; Aspirin 81 daily; Digoxin daily; hydrocodone-acetaminophen 5-325 as needed pain; Pravastatin 20 daily; ramipril 2.5 daily; zoloft 200 daily
Current Illness: Fell 2/4 and struck abdomen and ribs with large amount bruising Brought to ER 2/7 due to increased shortness of breath since COVID vaccine. Patient was admitted with CHF, hypoxia, possible aspiration pneumonia; NSTEMI (refused transfer for cardiology).
Preexisting Conditions: Dementia; CABG; HTN; MI; esophageal varices; Former smoker; liver cirrhosis; absent kidney
Allergies: Sulfa and vicodin
Diagnostic Lab Data: 2/7-2/8 hospital labs: BUN 29 Cr 1.43 GFR 48 Alk Phos 151 Lactic Acid 2.5 BNP 203 Troponin I 1.28 platelet count 78 COVID-19 Rapid Negative. Chest x-ray with hazy airspace opacities, CT Negative.
CDC Split Type:

Write-up: Fall 2/4 hospital admission 2/7/21 with death on 2/8/2021. Patient continued to decline on Bipap he was a DNR/DNI and family decided on comfort measures and he expired 2/8/2021.

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