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

This is VAERS ID 1592110



Case Details

VAERS ID: 1592110 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-05-05
Onset:2021-07-26
   Days after vaccination:82
Submitted: 0000-00-00
Entered: 2021-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0164 / 1 UN / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0164 / 2 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Dyspnoea, Pain, Pneumonia, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), 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: 2021-08-14
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol 300 mg QD, Amlodipine 5 mg QD, Aspirin 81 mg QD, Atorvastatin 40 mg QD, Carvedilol 6.25 mg BID, Docusate 100 mg BID, Gabapentin 400 mg QD, Metoclopramide 5 mg QD, Miralax 17 grams QD PRN, Sevelamer 3200 mg TID, Apresoline 100 mg
Current Illness:
Preexisting Conditions: Diabetes, ESRD on Dialysis, Hypertension
Allergies: Hydromorphone (Agitation)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pfizer BioNTech COVID-19 Vaccine EUA: COVID19 resulting in Hospitalization/ Death Patient received Pfizer Vaccines on 4/14/2021 and 5/5/2021. Patient presented to ED on 8/8/2021 with symptom onset 8/6/2021 of SOB, Cough, Fever, Body Aches, diagnosed with COVID-19 and pneumonia. Patient expired on 8/14/2021.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1592110

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