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

This is VAERS ID 1269848

Case Details

VAERS ID: 1269848 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Anion gap, Aspartate aminotransferase normal, Bilirubin conjugated increased, Blood albumin normal, Blood bilirubin increased, Blood chloride normal, Blood cholesterol normal, Blood creatinine increased, Blood glucose increased, Blood potassium normal, Blood sodium normal, Blood triglycerides increased, Blood urea increased, Brain natriuretic peptide increased, COVID-19, Death, EGFR status assay, Fatigue, Glycosylated haemoglobin increased, High density lipoprotein decreased, Hypophagia, Low density lipoprotein normal, Vitamin D
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Retroperitoneal fibrosis (broad), Biliary system related investigations, signs and symptoms (narrow), Pulmonary hypertension (broad), Lipodystrophy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-27
   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:
Diagnostic Lab Data: Report Released Date/Time: Feb 12, 2021@10:10 Specimen: SERUM. CH 0212 183 Specimen Collection Date: Feb 12, 2021@08:53 Test name Result units Ref. range Site Code SODIUM 139 mmol/L 135 - 145 POTASSIUM 4.6 mmol/L 3.5 - 5.0 CHLORIDE 105 mmol/L 100 - 110 CO2 21 mEq/L 20 - 30 UREA NITROGEN, BLOOD 26 H mg/dL 7 - 25 CREATININE,SERUM 1.5 mg/dL 0.5 - 1.5 eGFR(IDMS) 45 L mL/min Ref: $g=60 GLUCOSE,RANDOM 117 H mg/dL 65 - 100 ALBUMIN 3.7 g/dL 3.5 - 5.0 TOT. BILIRUBIN 1.14 mg/dL 0.2 - 1.2 DIR. BILIRUBIN 0.4 mg/dL 0.0 - 0.5 TRIGLYCERIDE 255 H mg/dL 0 - 199 CHOLESTEROL 199 mg/Eval: <200 mg/dL is desirable; 200-239 is borderline/high; $g=240 is high HDL 40 mg/dL Ref: $g=40 LDL 108.0 mg/dL 0 - 129 AST 16 U/L 5 - 40 ALT 21 7 - 52 ALKALINE PHOSPHATASE 80 U/L 40 - 150 ANION GAP 13 mEq/L 6 - 16 Reporting Lab: HEALTHCARE SYSTEM - Report Released Date/Time: Feb 12, 2021@08:52 Test name Result units Ref. range Site Code VITAMIN D TOTAL(SCREEN) 24.4 ng/mL 20.0 - 50.0 Reporting Lab: HEALTHCARE SYSTEM Report Released Date/TIme: Feb 12, 2021@09:55 Specimen: BLOOD. CH 0212 180 Specimen Collection Date: Feb 12, 2021#08:52 Test name Result units Ref. range Site Code HEMOGLOBIN A1C 6.4 H% Ref: <=5.6 [689] EST.AVERAGE GLUCOSE 137 mg/dL [689] Reporting Lab: HEALTHCARE SYSTEM Report Released Date/Time: Feb 12, 2021@10:21 Specimen: PLASMA. CH 0212 177 Specimen Collection Date: Feb 12, 2021@08:51 Test name Result units Ref. range BNP 150 H pg/mL 10 - 100
CDC Split Type:

Write-up: Death Narrative: Patient was admitted to facility from 1/11/2021 to 1/13/2021 for treatment of Covid 19 with symptoms of fatigue and poor oral intake. Admission was uneventful and follow-up notes post discharge from both Cardiology APRN and Primary Care Physician that the Patient was recovering well post admission. Patient received first of Covid Pfizer Vaccine on 4/2/2021 and second dose of Covid Pfizer Vaccine on 4/22/2021. Patient had been observed for 15 minutes after administration of each dose. No reaction was noted during the post vaccination observation period of either dose. Notice of death was received 5 days after second dose of Covid Vaccine from funeral home. There were no reports of an ADR occurring between observation period and death. There were no progress notes in patients chart between second Covid 19 Vaccine note 4/22/201 and death notice 4/27/2021. Cause of death is unknown at this time.

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