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

This is VAERS ID 1119002



Case Details

VAERS ID: 1119002 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Confusional state, Death, Dysphagia, Fatigue, Hypoxia, Incontinence, Pneumonia
SMQs:, Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 20 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: eliquis 5mg bid, lasix 20 mg bid, cardizem 30mg q8hrs, asprin 81 mg daily, KCl 20 meq every other day, prevastatin 40mg, famotadine 20mg bid, prozac 40 mg daily, levoythyroxine 50mcg daily, glycopyrrolate 1mg bid
Current Illness: none
Preexisting Conditions: CVA, hypertension, hyperlipidemia, atrial fibrillation, AAA, Pulmonary Embolism, OSA, hypothyroidism, dysphagia
Allergies: doxycycline
Diagnostic Lab Data:
CDC Split Type:

Write-up: Day 1-Confusion and weakness Day2-Increase in weakness, inability to swallow, confusion, fatigue Day 3-Weakness, confusion, incontinence, hospitalized for hypoxia, pneumonia Day 20- Deceased


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1119002

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