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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 1117213

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Case Details

VAERS ID: 1117213 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-03
Onset:2021-03-10
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN9581 / 1 RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9267 / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Cough, Dyspnoea, Infection, Monoclonal antibody immunoconjugate therapy, Pneumonia, SARS-CoV-2 test positive, Spinal compression fracture
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Osteoporosis/osteopenia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Medical records state a history of artheritis, chronic pain, dyslipidemia, GOUT, and former smoker.
Allergies: Medical records state an allergy to brimonidine and timolol.
Diagnostic Lab Data: 3/1/2021 COVID antigen test = positive 3/3/2021 COVID PCR test = positive
CDC Split Type:

Write-up: Case tested positive for COVID-19 on 3/1/2021 by rapid antigen and then again on 3/3/2021 by PCR. Case was admitted to hospital on 3/3/2021 for shortness of breath and occult infection. Case was previously admitted and discharged from hospital on 2/22/2021 after a lumbar compression fracture. Case had monoclonal antibody infusions; was afebrile and denied chills, but had a dry cough. Case was a previous smoker, quit 2 years prior. Case developed pneumonia. Case required supplemental oxygen.


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