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From the 1/14/2022 release of VAERS data:

This is VAERS ID 966178

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Case Details

VAERS ID: 966178 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Wisconsin  
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: acetaminophen 600 mg every 4 hrs, albuterol 2 puffs every 6 hrs, Symbicort 2puffs 2 x days, vitamin D, B12, Prozac 20 mg once per day, Veramyst 1 spray once per day, Lisinopril 5 mg once per day, Prilosec 40 mg once per day, Probiotic daily
Current Illness: skin ulcer of lower right leg due to old gun shot wound
Preexisting Conditions: alcoholism in remission, aortic stenosis-mild, arthritis, blood loss anemia, carpel tunnel syndrome bilateral, cellulitis of right leg, chronic insomnia, COPD, diverticulosis of sigmoid and descending colon, eczema, gun shot wound of leg, heart murmur-right upper external border, hemorrhoids, history of blood transfusion, history of falling, lyme disease, osteoarthritis of left knee, pneumonia, polyp of colon flat, peripyloric ulcer, peptic ulcer disease, sleep apnea, unspecified essential hypertension, viral meningitis
Allergies: aminoglycosides and sulfa meds
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pt called son to let him know he couldn''t breath around 2 AM. Pts son showed up at his house 10 minutes later and ambulance arrived with in 20 minutes at 2:15

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