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From the 7/16/2021 release of VAERS data:

This is VAERS ID 1130109



Case Details

VAERS ID: 1130109 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-20
Onset:2021-01-26
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Patient passed away unrelated to covid vaccination Narrative: The patient received his first dose of Pfizer vaccine on 1/20. Patient was on hospice and passed away at his home with family on 1/26. Cause of death not documented. No indication that death was related to COVID 19 vaccination.


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