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From the 5/14/2021 release of VAERS data (an older release, current is 11/12/2021):

This is VAERS ID 1037076

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Case Details

VAERS ID: 1037076 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-01-26
Onset:2021-01-30
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3200 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Confusional state, Death, Fall, Hip fracture, Hip surgery, Laboratory test, X-ray
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (broad), Osteonecrosis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol, Eliquis, Ativan, Gabepentin, Lasix, & others.
Current Illness: Hx Lung CA, COPD, dementia, A. Fib, Anxiety, edema, SOB
Preexisting Conditions: Lung Cancer, COPD, dementia, A. Fib, Anxiety, Edema, shortness of breath, neuropothy of lower limbs, hypertension
Allergies: Orange Juice
Diagnostic Lab Data: x-rays and labs completed during ER visit and hospitalization from 01/30/2021-02/03/2021
CDC Split Type:

Write-up: Resident developed increased confusion on 01/30/2021 that may have been related to vaccine or to residents other medical conditions including dementia, anxiety, shortness of breath, history of lung cancer, and COPD. Sustained a fall with fracture and was transferred to Hospital. Surgical intervention performed to repair hip. Resident returned to Skilled Nursing facility. Did not recover after surgery and family chose palliative measures. Resident died/ expired on 02/09/2021.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210514&IDNUMBER=1037076


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