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From the 11/26/2021 release of VAERS data:

This is VAERS ID 418006

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Case Details

VAERS ID: 418006 (history)  
Form: Version 1.0  
Age: 68.0  
Sex: Male  
Location: Idaho  
Vaccinated:2010-11-30
Onset:2010-11-30
   Days after vaccination:0
Submitted: 2011-03-01
   Days after onset:91
Entered: 2011-03-04
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 4 RA / IM

Administered by: Private       Purchased by: Private
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2010-11-30
   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: none at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC Split Type: ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


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