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

This is VAERS ID 1176120



Case Details

VAERS ID: 1176120 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Alaska  
Vaccinated:2021-03-19
Onset:2021-03-24
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER3302 / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Full blood count, Gastrostomy, Laboratory test, Metabolic function test, Nausea, Pain
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-24
   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: atorvostatin 20mg, belsomra 10mg, clopidogrel 75mg, famotidine 40mg, ondansetron 8mg, potassium chloride ER 20mEq, prochlorperazine maleate 10mg, quetiapine 100mg, sertraline 100mg, tamsulosin 0.4mg
Current Illness: Carcinoma of colon (stage IV), coronary atherosclerosis, GERD, hyperlipidemia, secondary malignant neoplasm of the bladder, TBI.
Preexisting Conditions: Carcinoma of colon (stage IV), coronary atherosclerosis, GERD, hyperlipidemia, secondary malignant neoplasm of the bladder, TBI.
Allergies: none
Diagnostic Lab Data: Standard labs drawn at hospital admission (due to pain and nausea from cancer treatment, possible suicide attempt) CBC and CMP drawn.
CDC Split Type:

Write-up: Patient died of expected causes 5 days post-vaccine. Patient was known to have advanced colon cancer. Patient''s COD was metastatic cecal cancer, admitted to hospital on 3/22/21 for palliative treatment, PEG tube placement for decompression, and pain control.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1176120

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