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From the 4/13/2011 release of VAERS data (an older release, current is 11/12/2021):

This is VAERS ID 413664

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Case Details

VAERS ID: 413664 (history)  
Form: Version .0  
Age: 88.0  
Sex: Male  
Location: Rhode Island  
   Days after vaccination:14
Submitted: 2010-12-28
   Days after onset:41
Entered: 2010-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Public       Purchased by: Other
Symptoms: Asthenia, Cerebrovascular accident, Chronic obstructive pulmonary disease, Condition aggravated, Death, Guillain-Barre syndrome, Hypoaesthesia, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (narrow), Ischaemic cerebrovascular conditions (narrow), Haemorrhagic cerebrovascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2010-12-02
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE NOTED
Preexisting Conditions:
Diagnostic Lab Data: No record available.
CDC Split Type:

Write-up: After 2 weeks SP immunization Resid - Began to c/o increased weakness & numbness. Sat -$g MD. Apt with MD. Started on neurontin 11/20. Sat on floor. L/T increased weakness. 11/21 -$g hosp with signs & sx of CVA.

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