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

This is VAERS ID 1218288



Case Details

VAERS ID: 1218288 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-04-13
Onset:2021-04-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8731 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Hypophagia, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen Tablet 325mg, 2 tabs by mouth
Current Illness: 1/20/2021 Admitted to Hospice for Myelodysplastic Anemia
Preexisting Conditions: Dementia, CVA, Hemiplegia,HTN,B12 Deficiency, Anemia, GI Refux, BPH and Dysphagia
Allergies: No Known Allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: 4/14/2021 at ~8am, Patient was out of bed and in his wheelchair and consumed 100% of his breakfast. During lunch time, he only consumed 25% of his meal. At ~2pm, patient was noted to be unresponsive. Oxygen saturation was 88% and B/P was low and oxygen was administered and Oxygen Saturation increased to 92%. The patient was placed in bed and Dr and the family were notified. The resident was continuously monitored by the Hospice nurse, who happened to be on-site and the primary nurse. At ~6:30pm it was noted that patient was having labored breathing so 0.25 ml of Morphine Sulfate Solution 20mg/ml was administered with releif. At 8:30pm, patient expired.


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