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

This is VAERS ID 1591931

Case Details

VAERS ID: 1591931 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Texas  
   Days after vaccination:122
Submitted: 0000-00-00
Entered: 2021-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, COVID-19, Death, Dyspnoea, General physical health deterioration, Pneumonia, Renal transplant, SARS-CoV-2 antibody test negative, SARS-CoV-2 test positive
SMQs:, Acute renal failure (broad), Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-11
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 16 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: fluconazole 100 mg QD, furosemide 80 mg QD, gabapentin 100 mg BID, Insulin Lispro sliding scale TID, Mycophenolate 720 mg BID, Oxycodone 5 mg Q4h PRN, Polyethylene glycol 17 grams PRN, Prednisone 5 mg QD, Senna+Docusate PRN, Sulfamethoxazol
Current Illness:
Preexisting Conditions: Hyperlipidemia, Hypertension, Anemia in ESRD, Retinal Edema, Chronic venous hypertension w/ ulcer, Mild intermittent asthma, Seasonal allergies, Type 2 diabetes mellitus, End Stage Renal Disease, Chronic Dialysis, OSA on CPAP, Metabolic bone disease, secondary hyperparathyroidism, hyperkalemia, history fo CVA with residual effects, diverticulosis of colon without diverticulitis, Obesity, Coronary artery disease, GERD, History of Junctional dysrhythmia
Allergies: Chlorhexidine (Dermatitis)
Diagnostic Lab Data: Positive COVID-19 test 07/27 @ 1827 using PCR Positive COVID-19 test 07/30 @ 1220 using PCR Negative SARS CoV2 Antibodies
CDC Split Type:

Write-up: Pfizer BioNTech COVID-19 Vaccine EUA: Fully Vaccinated Expired Patient received Pfizer Vaccines on 3/5/2021 and 3/26/2021. Patient had a history of ESRD secondary to diabetes and hypertension, renal transplant on 7/13/2021, and was admitted on 7/26/2021 through ED for worsening shortness of breath, weakness and dyspnea. Patient found to be positive for COVID-19 and pneumonia. Patient was treated with remdesivir, dexamethasone, and piperacillin+Tazobactam. Patient continued to decline and expired on 8/11/2021

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