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

This is VAERS ID 1433430



Case Details

VAERS ID: 1433430 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-01-08
Onset:2021-05-03
   Days after vaccination:115
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 UN / UN
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 2 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, 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: 2021-05-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Diabetes mellitus Chronic kidney disease Morbid obesity, BMI 65
Allergies: Unknown
Diagnostic Lab Data: Positive COVID-19 PCR test result 04/13/2021
CDC Split Type: 3637161

Write-up: Died of COVID-19 illness on 05/03/2021


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1433430

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