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From the 2/26/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 1050158



Case Details

VAERS ID: 1050158 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-28
Onset:2021-02-23
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Pulmonary congestion, Respiratory tract congestion, Vomiting
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   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: Tramadol HCI tab 50mg po Qday, Ambien titrate 5 mg PO QHS PRN, Promethazine DM Syrup 6.25-15mg/5ml give 5ml Q4hrs prn, Zofran 4mg 1 tab PO Q 4 hours PRN, Morphine sulfate 15mg give 0.5mg PO Q 4hours PRN , Bowel care
Current Illness: Dementia, History of CVA affecting left side, history of COVID 19 in December 2020, Aphasia.
Preexisting Conditions: Dementia, History of CVA affecting left side, history of COVID 19 in December 2020, Aphasia.
Allergies: No known allergies
Diagnostic Lab Data: Change of condition was acute and on same day passed away - 1-23-2021
CDC Split Type:

Write-up: Resident is a Hospice patient. On 1-23-2021 am shift resident was observed by nursing have chest congestion and had a emesis times 1 with SOB, Zofran 4 mg was given. HOB (02 sats 88%) was elevated resident on 02 via nasal canula with 02 sat now @ 90% . no respiratory distress noted. MD was called with response pending for orders. @ 1400 resident with no signs of life. vs 90%-24-97/71-97.6. Hospice on site and time of death 1436


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210226&IDNUMBER=1050158

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