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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1764974

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Case Details

VAERS ID: 1764974 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Male  
Location: New Hampshire  
Vaccinated:2021-06-14
Onset:2021-06-20
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Arthralgia, Autopsy, Drowning, Gene sequencing, Intracardiac mass, Myocardial necrosis, Myocarditis, Pain, Pathology test, SARS-CoV-2 test negative, Subgaleal haemorrhage, Toxicologic test normal, Ventricular hypertrophy
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Accidents and injuries (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Neonatal disorders (narrow), Arthritis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-20
   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: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Autopsy report 6/21/2021. Pertinent findings include: no external indication of scalp injury, with small subgaleal hemorrhage over the left occiput; normal epidural, subdural, and subarachnoid evaluations; mildly elevated cardiac mass 420 mg; normal pericardial appearance; normal coronary artery origins from the aorta and free of atherosclerosis; increased left ventricular wall thickness (1.8 cm) and normal right ventricular wall thickness (0.3 cm); normal gross appearance of the endocardium, myocardium, and cardiac valves; small foci of myocardial inflammation of the lateral wall of the left ventricle with myocyte necrosis; negative myocyte disarray; negative toxicology; negative SARS-CoV-2 RT-PCR; Ambry Genetics CardioNext analysis of 92 genes associated with inherited cardiomyopathies and arrhythmias negative for pathologic findings, positive for 2 variants of unknown significance.
CDC Split Type:

Write-up: He was in his usual state of good health. 5 days after receiving the vaccine, he complained of brief unilateral shoulder pain (unclear to family which shoulder), which the family attributed to a musculoskeletal source. No chest pains, shortness of breath, or palpitations. He was playing with 2 friends at a community pond, swinging from a rope swing, flipping in the air, and landing in the water feet first. He surfaced, laughed, told his friends "Wow, that hurt!", then swam toward shore, underwater as was his usual routine. The friends became worried when he did not re-emerge. His body was retrieved by local authorities more than an hour later.


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