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From the 4/8/2021 release of VAERS data:

This is VAERS ID 1041990



Case Details

VAERS ID: 1041990 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2020-12-28
Onset:2021-01-15
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH E10140 / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acidosis, Body temperature decreased, COVID-19 pneumonia, Chest X-ray abnormal, Death, Hypotension, Intensive care, International normalised ratio increased, Mental status changes, Metabolic function test abnormal, Sepsis, Septic shock, Urinary tract infection
SMQs:, Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Toxic-septic shock conditions (narrow), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Tumour lysis syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Covid IN NOVEMBER
Preexisting Conditions: CKD , CAD WITH STATUS POST CABG , HTN HYPOTHYROIDISM, DEMENTIA AND RECURRENT UTI
Allergies: nkda
Diagnostic Lab Data: CXRAY - COVID PNA bmp - SEVERE ACIDOSIS TEMPERTURE 94 BEAR WARMER HYPOTENSION LEVOPHED AND 3L OF ns O2 AT 3L inr 2.09 WITHOUT COUMIDIN
CDC Split Type:

Write-up: PATIENT WAS ADMITTED TO ER FOR ALTERED MENTAL STATUS / UTI SEPSIS WITH SEPTIC SHOCK / COVID AND COVID PNA PATIENT WAS ADMITTED TO ICU AND DIED . POA WISH TO WITHDRAWL EXTRME MEASURES


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1041990


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