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From the 6/11/2021 release of VAERS data:

This is VAERS ID 404792



Case Details

VAERS ID: 404792 (history)  
Form: Version 1.0  
Age: 75.0  
Sex: Male  
Location: Utah  
Vaccinated:2010-10-13
Onset:2010-10-14
   Days after vaccination:1
Submitted: 2010-10-19
   Days after onset:5
Entered: 2010-10-21
   Days after submission:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE) / SANOFI PASTEUR U3635AA / UNK UN / UN

Administered by: Unknown       Purchased by: Unknown
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2010-10-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: The patient had a history of chronic conditions including severe cardiopulmonary issues (unspecified), cataracts, and was "crippled". The reporter stated the patient had been very ill and his quality of life was poor. The patient received an influenza vaccine annually. Follow-up on 18 October 2010: Per the reporter, the patient''s medical history of cardiopulmonary issues (unspecified) was "more cardiac rather than pulmonary", but no specifics were provided.
Allergies:
Diagnostic Lab Data: Not reported.
CDC Split Type: 201005967

Write-up: Initial information received from a health care professional on 15 October 2010. A 75-year-old male patient with a history of severe cardiopulmonary issues (unspecified), cataracts, and who was "crippled", received a dose of FLUZONE HIGH-DOSE No Preservative 2010-2011, lot number U3635AA, on 13 October 2010 at 10:00 a.m. The route and site of vaccination were not reported. Following vaccination, the patient experienced no adverse events or reactions and was reported to be "fine" at 8:30p.m. that evening. The following day, on 14 October 2010 at 11:00 a.m., he was found dead by his sister. Autopsy status is unknown and no cause of death was reported. Per the reporter, the patient had been very ill prior to vaccination and his quality of life was poor. Follow-up information received on 18 October 2010 from a health care professional. The reporter stated that it is unknown if an autopsy was planned for the patient, but that if the patient had been seen by one of their physicians during the month prior to the event it is unlikely an autopsy would be performed. In addition, the reporter stated that the patient''s past medical history of cardiopulmonary issues (unspecified) were "more cardiac rather than pulmonary", but no specifics were provided. List of documents held by sender: none


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