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From the 11/19/2021 release of VAERS data:

This is VAERS ID 959079

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Case Details

VAERS ID: 959079 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Colorado  
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Bundle branch block right, Electrocardiogram QRS complex abnormal, Heart rate increased, Pain, Respiratory rate increased, Sinus tachycardia, Supraventricular tachycardia, Vital functions abnormal
SMQs:, Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Supraventricular tachyarrhythmias (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ascorbic Acid 500mg, Cetirizine HCL 5mg, Escitalopram Oxalate 10mg, Finasteride 5mg, Metoprolol succinate ER 25mg, Tamsulosin 0.4mg, Teriparatide 20mcg injection, Vitamin D3 Tablet, voltaren Gel 1%, Eliquis 5mg, Pantoprazole Sodium 40mg, Ac
Current Illness: Residents condition was declining over the past several months and has been treated for depression and dementia. Resident refusing care including meals, medication and ADL care.
Preexisting Conditions: Atrial Fibrillation, obstructive uropathy, chronic kidney disease, asthma, bradycardia, major depression, dysphagia, Parkinson''s disease, dependence on supplemental oxygen, osteoporosis, hyperlipidemia,
Allergies: No Known Allergies
Diagnostic Lab Data: 1/9/2021- 12 lead EKG performed which states sinus tachycardia with supraventricular complexes and low voltage QRS as well as right bundle 1/9/2021- CXR ordered but discontinued at request of POA
CDC Split Type:

Write-up: On 1/9/2021 observed with elevated respirations of 38-42 per minute, BP manually 72/50. pulse is jumping rapidly between 110-16 bpm. oxygen sat 76% RA, resident refusing oxygen at first attempt, allowed oxygen to be placed, is now 84% on 4L. resident shaking head yes that he is hurting, and yes that he would take medication for pain. Dr. notified, branch block. Received order for morphine 2mg per hr as needed for elevated respirations and pain. Dr. also gave orders to D/C Tamsulosin and finasteride. Resident continue with decreased O2 sats and elevated respirations. Absence of vital signs on 1/10/21 at 826PM.

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