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From the 4/30/2021 release of VAERS data:

This is VAERS ID 1003106



Case Details

VAERS ID: 1003106 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-04
Onset:2021-02-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pupil fixed, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Enteric Coated Aspirin 81 mg tablet,delayed release 1 Time Daily Eliquis 2.5 mg tablet 2 Times Daily Dulcolax (bisacodyl) 10 mg rectal suppository PRN Fleet Enema 19 gram-7 gram/118 mL PRN acetaminophen 500 mg ta
Current Illness: CARDIOMEGALY; LOW BACK PAIN; MUSCLE WEAKNESS (GENERALIZED); NEED FOR ASSISTANCE WITH PERSONAL CARE; - OTHER ABNORMALITIES OF GAIT AND MOBILITY; LUMBAGO WITH SCIATICA, UNSPECIFIED SIDE; R26.81 - UNSTEADINESS ON FEET; REPEATED FALLS; CERVICAL SPONDYLOSIS; Other Diagnoses PRESENCE OF CARDIAC PACEMAKER; DYSPHAGIA, OROPHARYNGEAL PHASE; HYPERLIPIDEMIA, UNSPECIFIED; CHRONIC ATRIAL FIBRILLATION, UNSPECIFIED ; ATHSCL HEART DISEASE OF NATIVE CORONARY ARTERY W/O ANG PCTRS; ESSENTIAL (PRIMARY) HYPERTENSION; INSOMNIA, UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE;
Preexisting Conditions: On hospice
Allergies: Diltiazem
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident received vaccination at 9:12 am, she was monitored and checked at the 15 minute interval 9:27 am, reassessed, vitals were fine. Within 20 (9:32 am) minutes of receiving the vaccine she was unresponsive, pupils were fixed at 9:45 am, no vital signs noted; hospice came out and reported her time of death 10:21 am. This person was on hospice.


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=1003106


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