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

This is VAERS ID 1074894



Case Details

VAERS ID: 1074894 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-26
Onset:2021-02-11
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood chloride increased, Blood chloride normal, Blood creatinine increased, Blood sodium increased, Blood urea increased, Death, Glomerular filtration rate normal, Influenza A virus test negative, Influenza virus test negative, Pneumonia, SARS-CoV-2 test negative
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Retroperitoneal fibrosis (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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: Eliquis, Metoprolol succinate, Upcal w/Vitamin D, senna, levothyroxine, vitamin D3
Current Illness: None
Preexisting Conditions: Cerebrovascular disease, vascular dementia, ASCVD, CAD, PVD, HTN, CHF, Afib, Hyperlipidemia, DMII, Hypothyroidism, OA, DJD, DDD, gout, CKD stage 3a, BPH, GERD, Vitamin D deficiency, osteopenia
Allergies: Bactrim DS, Zetia, Flomax, Crestor, Proscar
Diagnostic Lab Data: 2/10/21: BUN=58, Cr=1.7, EGFR=40, Na=154, Cl=120 2/11/21: COVID-19 swab negative 2/2/21: Influenza A&B negative
CDC Split Type:

Write-up: Patient became ill with pneumonia on 1/29/21 and then recurrent pneumonia on 2/10/21. Pt''s plan of care was subsequently changed to comfort-focused on 2/11/21 and patient was deceased that same day.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1074894

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