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From the 10/15/2021 release of VAERS data:

This is VAERS ID 969488



Case Details

VAERS ID: 969488 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-01-11
Onset:2021-01-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram, Fatigue, Full blood count, Haematoma, Metabolic function test, Myalgia, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: losartan, doxazosin, metoprolol, Areds 2 eye vitamins
Current Illness: Covid 19
Preexisting Conditions: hypertension
Allergies: No
Diagnostic Lab Data: CBC, BMP, CT
CDC Split Type:

Write-up: Fatigue, muscle aches, vomiting, hematoma


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