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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1148157

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Case Details

VAERS ID: 1148157 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-05
Onset:2021-02-10
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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: Bumetanide, Prednisone, Ativan, senna, aspercreme, Geri-Tussin, Acetaminophen, Morphine
Current Illness: Hematuria
Preexisting Conditions: Diabetes, TIA, Falls, Dementia
Allergies: No Known Allergies
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Hospice Care, Crisis Care, Expired.


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=1148157


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