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

This is VAERS ID 961010

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Case Details

VAERS ID: 961010 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-01-19
Onset:2021-01-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram head normal, Ecchymosis, Haematoma, Troponin increased
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Myocardial infarction (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: encephalopathy; gastritis unspecified with bleeding; essential primary HTN; benign prostatic hyperplasia without lower urinary tract sx; hypothyroidism; hyperlipidemia; spinal stenosis; sacral and sacro ccygeal region; anxiety; atrial fibrillation; GERD without esophagitis; edema unspecified; weakness; dementia; hammer toe acquired right foot
Allergies: Hydralazine
Diagnostic Lab Data: 1/19/2021 CT of head negative 1/19/2021 Troponin 3,000
CDC Split Type:

Write-up: Resident returned to the memory support unit at 1500. Resident was than toileted and transferred in to bed per his request. At 1515 resident was observed face down beside bed, resident sustained a 1inX1in eccyhmotic/hematoma to the forehead. Neuro Checks with in normal limes Vital signs: 100/52, 100, 97.2, 28. Resident sent to ED for further medical evaluation via EMS.


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