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

This is VAERS ID 1371516



Case Details

VAERS ID: 1371516 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-19
Onset:2021-05-21
   Days after vaccination:91
Submitted: 0000-00-00
Entered: 2021-06-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Polymerase chain reaction
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-26
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: AMIODARONE, DALIRESP, DIVALPROEX, FLUOXETINE, INCRUSE ELLIPTA, LEVOTHYROXINE, METAMUCIL, OMEPRAZOLE, TRAZODONE, LORAZEPAM, PHENYTOIN SODIUM, RISPERDAL, URSODIOL, DIAZEPAM, HYDROXYZINE, NORCO 10-325, VENTOLIN HFA, CARBIDOPA-LEVODOPA
Current Illness:
Preexisting Conditions: SEIZURE DISORDER, COPD, PARKINSON''S, PARANOID SCHIZOPHRENIA, HX OF TBI, DEMENTIA
Allergies: Amoxicillin, Cephalexin, Codeine, Dye, Red, Dye, Tartrazine, Dye, Yellow, Methylprednisolone, Tramadol, Flonase
Diagnostic Lab Data: PCR TEST DONE AT HOSPICE HOUSE
CDC Split Type:

Write-up: PASSED AWAY AT THE HOSPICE HOUSE


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