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

This is VAERS ID 1364864



Case Details

VAERS ID: 1364864 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-02
Onset:2021-05-08
   Days after vaccination:67
Submitted: 0000-00-00
Entered: 2021-06-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6205 / 2 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, SARS-CoV-2 test, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: 5/8/2021SARS COVID PCR detected 5/12/2021 SARS-CoV-2
CDC Split Type:

Write-up: First dose given 2/9/2021 see further information below. Date of death 5/16/2021. Hospital 5/8/2021 to 5/16/2021


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1364864

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