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

This is VAERS ID 1038290

Case Details

VAERS ID: 1038290 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Illinois  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Blood creatinine increased, Blood urea increased, Death, Glomerular filtration rate, Lymphocyte percentage decreased, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine-benazapril; atorvastatin; basaglar Kwikpen; citalopram; clopidrogel; coreg; fenofibrate; glipizide; hydrochlorothiazide; metformin; pantoprazole; ropinirole
Current Illness: Outpatient admission 1/25-1/27 with Hypertension urgency and inability to care for self at home, discharged to Agency; 1/28/21 had a choking episode and continued to decline from there. ER 1/31 and 2/1 for low grade fever and continued decline returned to SNF and wife placed patient on hospice.
Preexisting Conditions: Apnea; diabetes; dyslipidemia; ischemic stroke; prostate disorder; multiple CVAs with residual weakness
Allergies: Sulfa
Diagnostic Lab Data: ER 1/31-2/1 WBC 10.62; Lymph 11.3%; BUN 35; Cr 1.58; GFR 44;
CDC Split Type:

Write-up: Death on same day as vaccination

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