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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1039250



Case Details

VAERS ID: 1039250 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-01-30
Onset:2021-02-14
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   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:
Preexisting Conditions: dementia
Allergies: unknown
Diagnostic Lab Data: Medical Examiner''s Office will perform postmortem COVID-19 testing at this time.
CDC Split Type:

Write-up: Daughter of decedent reported that he quickly declined within 2 weeks of receiving vaccine and developed shortness of breath. Decedent received vaccine 1/30/2021 and died 2/15/2021. Only received first dose of series.


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