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

This is VAERS ID 1047072



Case Details

VAERS ID: 1047072 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-13
Onset:2021-02-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, General physical health deterioration, Haemoptysis, Headache, Oxygen saturation decreased, Pain, Pain in extremity, Pyrexia
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (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? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Topamax,
Current Illness: COPD, seizures( patient on medications and controlled), Hernia operation 2 years ago
Preexisting Conditions: COPD and seizures, asthma
Allergies: no allergies to medications, or food but allergic to cats
Diagnostic Lab Data: not provided
CDC Split Type:

Write-up: Patient had sore arm on the day of vaccination. Per patient''s nephew , the next morning patient experienced body pains, aches, headache . Onn Tuesday patient had fever. Patient''s condition progressively got worse. He had difficulty breathing by Wednesday night. He had low oxygen levels at 80 per pulse ox reading. Patient was coughing up blood. Family took him to hospital on Thursday morning due to breathing difficulty and patient died 2.18.21 at 10 am


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1047072

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