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

This is VAERS ID 1122969



Case Details

VAERS ID: 1122969 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: New Hampshire  
Vaccinated:2021-02-18
Onset:2021-03-21
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   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: 2/18/21 Aspirin Tablet Chewable 81 MG; MiraLax Powder (Polyethylene Glycol 3350) Give 17 gram by mouth in the morning; Probenecid Tablet 500 MG Give 1 tablet by mouth in the morning; Senna-S Tablet 8.6-50 MG-Give 2 tablet by mouth in the mo
Current Illness: Overall general decline in condiition. Parkinson''s disease and atrial fibrillation anticoagulated on Coumadin. He has a history of sigmoid thickening suspicious for malignancy. He has been followed by palliative care. He has congestive heart failure with chronic lower extremity edema. He has been followed by palliative care. Symptomatic and tested positive for Covid + 12/16. Did not qualify for monoclonal antibodies. 1/8 Resident with order to admit to Hospice services due to overall decline, poor appetite, weight loss. Admitted to Hospice Services 1/13. First Covid vaccine received on 1/29/2021. Ongoing restlessness, increased hallucinations and behaviors. Ativan scheduled and increased. 2/2 Desatting into 70''s-80''s. O2 started with rapid improvement noted and able to wean off within 48 hrs. Started on Seroquel for increased agitation and psychosis. 2/18 received 2nd vaccine. Seroquel increased 2/18. Ongoing decline over the next month with deterioration in condition, weight loss, wounds etc.
Preexisting Conditions: PARKINSON''S DISEASE HEART FAILURE, UNSPECIFIED DYSPHAGIA, OROPHARYNGEAL PHASE COGNITIVE COMMUNICATION DEFICIT ANXIETY DISORDER, UNSPECIFIED CHRONIC VENOUS HYPERTENSION W ULCER OF L LOW EXTREM TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS UNSPECIFIED ATRIAL FIBRILLATION MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED PRESSURE ULCER OF SACRAL REGION, STAGE 2 PERSONAL HISTORY OF COVID-19 PERSONAL HISTORY OF (HEALED) TRAUMATIC FRACTURE OTH DISRD OF BONE DENSITY AND STRUCTURE, UNSPECIFIED SITE OTHER INTERVERTEBRAL DISC DEGENERATION, LUMBAR REGION CHRONIC VENOUS HYPERTENSION W ULCER OF R LOW EXTREM HYPOTHYROIDISM, UNSPECIFIED PERIPHERAL VASCULAR DISEASE, UNSPECIFIED LIPOMATOSIS, NOT ELSEWHERE CLASSIFIED MALIGNANT NEOPLASM OF SIGMOID COLON GASTROINTESTINAL HEMORRHAGE, UNSPECIFIED OTHER SPECIFIED DISEASES OF INTESTINE ANEMIA, UNSPECIFIED ELEVATED PROSTATE SPECIFIC ANTIGEN [PSA] HYPERLIPIDEMIA, UNSPECIFIED ALCOHOL ABUSE, UNCOMPLICATED ATHSCL NATIVE ARTERIES OF RIGHT LEG W ULCER OF UNSP SITE UNSPECIFIED GLAUCOMA VITAMIN D DEFICIENCY, UNSPECIFIED BASAL CELL CARCINOMA OF SKIN OF OTHER PART OF TRUNK HEMANGIOMA OF SKIN AND SUBCUTANEOUS TISSUE OTHER SEBORRHEIC KERATOSIS ENCOUNTER FOR SCREENING FOR MALIGNANT NEOPLASM OF PROSTATE IDIOPATHIC CHRONIC GOUT, MULTIPLE SITES, WITH TOPHUS (TOPHI AGE-RELATED NUCLEAR CATARACT, BILATERAL OBESITY, UNSPECIFIED ESSENTIAL (PRIMARY) HYPERTENSION
Allergies: No known allergies
Diagnostic Lab Data: Covid + 12/14
CDC Split Type:

Write-up: Resident Expired at facility on Hospice services on 3/21/21


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