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

This is VAERS ID 28753

Case Details

VAERS ID: 28753 (history)  
Form: Version 1.0  
Age: 80.0  
Sex: Male  
Location: California  
   Days after vaccination:1
Submitted: 1990-11-30
   Days after onset:6
Entered: 1991-03-04
   Days after submission:94
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Public
Symptoms: Cough, Depression, Dizziness, Dyspnoea, Hyperhidrosis, Pallor, Pharyngitis, Pyrexia
SMQs:, Anaphylactic reaction (broad), Agranulocytosis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal infections (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1990-11-29
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Robitussin; Amoxicillin, 02, "routine cardiac meds"
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data:
CDC Split Type: CA9130

Write-up: Began URI w/fever 24NOV90, treated w/ Robitussin. Coughing, fever & depression continued 26NOV90 rx Amoxicillin. Better & up walking 28NOV but @ 5PM was pale, dizzy, sweaty & had SOB.

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