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

This is VAERS ID 1109696



Case Details

VAERS ID: 1109696 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: New York  
Vaccinated:2020-12-31
Onset:2021-01-04
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myocardial infarction, Atrial fibrillation, Blood lactate dehydrogenase increased, COVID-19, Death, Dyspnoea, Metabolic function test normal, Multiple organ dysfunction syndrome, SARS-CoV-2 test positive, Sepsis, Serum ferritin increased, Staphylococcal bacteraemia
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: atorvastatin, omeprazole, folic acid, furosemide, methotrexate weekly, metoprolol, ozempic
Current Illness: tested positive for covid 19 on 12/14/2021
Preexisting Conditions: HTN, DM, arthritis, ckd , hyperlipidemia
Allergies: None
Diagnostic Lab Data: LDH 8396, Ferritin 25902, CMP on arrival normal. Was known covid positive since 12/14.
CDC Split Type:

Write-up: Pt presented to the ER on 1/4 2021 with worsening sob, found to have acute ST elevation MI and new rapid atrial fib with RVR. He tested positive for covid 19 requiring new oxygen and received his first pfizer vaccine on 12/31. He was acutely transferred to rochester general hospital. He progressed to multiorgan failure, sepsis, mrsa bacteremia and died on 1/14/2021


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