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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1362511

Case Details

VAERS ID: 1362511 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Arizona  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Back pain, Blood calcium decreased, Blood chloride decreased, Blood glucose increased, Blood sodium decreased, Brain natriuretic peptide normal, Chest X-ray abnormal, Chills, Condition aggravated, Cough, Death, Diarrhoea, Differential white blood cell count abnormal, Dyspnoea, Eye pain, Fatigue, Feeling abnormal, Fibrin D dimer increased, Full blood count abnormal, Haematocrit increased, Haemoglobin increased, Headache, Hyperaesthesia, Influenza virus test negative, Laboratory test normal, Legionella test, Lung disorder, Lung opacity, Lymphadenopathy, Lymphadenopathy mediastinal, Metabolic function test abnormal, Monocyte count increased, Oropharyngeal pain, Pain, Pain of skin, Platelet count decreased, Pleural effusion, Procalcitonin, Protein urine present, Pyrexia, Rash, Red blood cell count increased, SARS-CoV-2 test negative, Sepsis, Shock, Streptococcus test negative, Troponin I normal, Urine analysis abnormal, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Haematopoietic leukopenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (narrow), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Dementia (broad), Pseudomembranous colitis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Glaucoma (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Myelodysplastic syndrome (broad), Noninfectious diarrhoea (narrow), Tumour lysis syndrome (broad), Proteinuria (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zyrtec 10mg, CBD Oil Thoughtcloud Sublingual
Current Illness: Possible illness 2 days prior to vaccine - achey from golf/pil. Thought achey from golf and pilates possibly. Stress. High Cholesterol.
Preexisting Conditions: High Cholesterol
Allergies: seasonal and pollens/trees/grasses
Diagnostic Lab Data: 2/26/21 UrgentCare: Flu test - neg, Covid-19 test - neg, Chest xray - normal ? 2/28/21 UrgentCare: Urine test - neg, BMP=abnormal: 105H glucose, 134L sodium, 8.3L calcium CBC=ab. CBC=abnormal: 122L platelet count 3/1/2021 HOSPITAL Chest Xray - diffuse patch opacities, moderate central and lower lung predominant opacity which could reflect pneumonia, acute edema might have this appearance however there is no cardiac enlargement or pleural effusion to etiology; CTA chest - Mildly limited at detailed in xray, no pulmonary embolism found, moderate diffuse interlobular septal thickening and patch lung opacity, this could reflect alveolar and interstitial edema or pneumonia, small bilateral pleural effusions, mild mediastinal adenopathy, possible hilar adenopathy, and mild left axillary adenopathy; CBCwDif=abnormal RBC 6.16H, Hemoglobin 18.5H, Hematocrit 54.9H, Platelets 73L, Monocytes Absolute .96, BMP=abnormal Sodium 129L, Choride 95L, Calcium 8.3L, Glucose 150H; UAwMicro=abnormal 100 protein; D-Dimer Quant=abnormal 1.52; Troponin I=normal, B-type natriuretic peptide=normal, POC Covid-19 test=negative, Molecular, ABBOTT ID Now; Procalcitonin ?; Leionella=neg; Pneumococcal antigen=neg; Strep Pneomo antigen urine=neg
CDC Split Type:

Write-up: Skin hurting/sensitivity (Day 1 forward), severe chills (day 2 forward), headache (day 1 forward), fatigue (day 1 forward), mild cough on/off, eye pain (? day 4 forward), achey (day 1 forward), chest rash (? day 3 forward), fever (? day 5 forward 101.9 day 5), back pain (? day 5 forward), labored breathing (? day 5 forward), diarrhea (? day 5 forward), sore throat (? day 5 forward) vomit (day 7). Symptoms of chills and miserable feeling increased day 4 on. Tylenol, Albuterol on day 6, Day 8 hospitalized, antibiotics and oxygen, Sepsis and shock, less than one day in hospital - passed on 3/2/21 am.

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