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

This is VAERS ID 1036748

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Case Details

VAERS ID: 1036748 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Illinois  
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Albumin globulin ratio abnormal, Aspartate aminotransferase increased, Blood albumin decreased, Blood alkaline phosphatase increased, Blood bilirubin increased, Blood creatinine increased, Blood pressure decreased, Blood urea increased, Condition aggravated, Death, Dialysis, Globulins increased, Loss of consciousness, Lymphocyte percentage decreased, Pneumonia, Protein total normal, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haematopoietic leukopenia (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Biliary system related investigations, signs and symptoms (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Tylenol prn; aspirin daily; atorvastatin daily; calcium carbonate daily; cholecalciferol twice daily; diltiazem; eliquis; ferrous sulfate; norco; melatonin; miralax; namenda; tamsulosin; tramadol every 6hrs.
Current Illness: ER visit 1/7 due to fall, CT negative current Dialysis, pneumonia, hospice patient.
Preexisting Conditions: DVT, dementia, hep c, hyperlipidemia; occlusion of internal carotid artery; paroxysmal Afib; traumatic brain injury
Diagnostic Lab Data: 1/14/21 WBC 25.38; bun 23; cr 2.92; total protein 7.7; albumin 2.0; globulin 5.7; a/g ratio 0.4; total bili 3.6; alk phos 1743; SGOT 193; SGPT 82; lymph 7%
CDC Split Type:

Write-up: Sent to ER 1/14/2021 due to drop in blood pressure with LOC during dialysis. Imaging revealed right lower lobe pneumonia given script for amoxicillin. According to staff patient was on dialysis had pneumonia and was on hospice, dialysis stopped resulting in death.

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