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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 1274462

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Case Details

VAERS ID: 1274462 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Kentucky  
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood potassium decreased, Cerebrovascular accident, Condition aggravated, Death, Pneumonia, Pneumonia aspiration
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-26
   Days after onset: 73
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: Carvedilol 3.125mg, Potassium CL ER 10meq, Tylenol500mg, Eliquis5mg,Roxicodone 5mg, Prednisone 10mg, Gabapentin 300mg,Sennosides-Docusate Sodium Tablets 8.6-50mg,, Omeprazole DR 20mg,,Tamulosin HCL 0.4mg
Current Illness: CVA, Chronic Kidney Disease, Emphysema, Chronic Bronchitis, Atrial Fibrillation, Ischemic Heart Disease, Hypertension
Preexisting Conditions: Please see answer above.
Allergies: Keflex
Diagnostic Lab Data: Please see above for the hospital dates.
CDC Split Type:

Write-up: Resident developed and was being treated for pneumonia on or about February 14, 2021, He was admitted to hospital on March 6, 2021 for low potassium and returned to the facility about March 11,2021. He returned with a diagnosis of pneumonia. He was admitted hospital on 4-1-2021 and returned to the facility on 4-7-2021 with a diagnosis of CVA. He was admitted to hospital again on 4-12-2021 with a diagnosis of aspiration pneumonia. He returned to the facility on 4-21-2021 and expired at the facility on 4-26-2021

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