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

This is VAERS ID 1124382



Case Details

VAERS ID: 1124382 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-13
Onset:2021-03-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6205 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Fall, Respiratory arrest, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient received first COVID vaccine does on 3/13/21 at 07:53 without complications. Home telehealth nurse informed by family member on 3/18/21 the patient passed away on 3/13/21 at approximately 1300. Per medical record documentation, "Patient had been at facility getting COVID vaccine that morning at 0800, came home and was taking out his garbage when he started to stumble and fell to his knee, a neighbor saw and assisted patient up and was walking with him back to the apartment when "...he stopped breathing and feel over, dead." Per medical record review, patient had several co-morbidities including hypertension, hyperlipidemia, chronic hyponatremia, alcohol abuse, alcoholic fatty liver, chronic thrombocytopenia, and GERD.


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