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From the 5/14/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1051666

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Case Details

VAERS ID: 1051666 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Ohio  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Public       Purchased by: ?
Symptoms: Anaemia, Arteriosclerosis, Blood lactic acid increased, Cardiac failure congestive, Chest X-ray abnormal, Computerised tomogram thorax abnormal, Computerised tomogram thorax normal, Condition aggravated, Death, Dyspnoea, Electrocardiogram normal, Emphysema, Endotracheal intubation, Fibrin D dimer increased, Mitral valve incompetence, Pulmonary oedema, Tricuspid valve incompetence
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Haematopoietic erythropenia (broad), Lactic acidosis (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Acute central respiratory depression (broad), Pulmonary hypertension (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: CHF,DM2,OSA,HTN,Diabetic Neuropathy, CKD3
Allergies: Heparin,Cipro,Imdur
Diagnostic Lab Data: CT PE Study: No PE, mild to moderate emphysematous changes,bil renal stones, no acute inflammatory process in the abdomen or pelvis. XR Chest: No acute cardiopulm disease. EKG: ventr
CDC Split Type:

Write-up: Pt presented to ER with SOB on 01-29-2021. He was admitted to Healthcare with acute CHF exacerbation, elevated lactate, anemia and elevated d-dimer. Pt reports getting SOB getting up to go to the bathroom. Pt was intubated. He developed pulmonary edema. Pt expired on 02-02-2021 at 10:13 PM.

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