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From the 5/13/2011 release of VAERS data (an older release, current is 1/7/2022):

This is VAERS ID 414974

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Case Details

VAERS ID: 414974 (history)  
Form: Version .0  
Age: 76.0  
Sex: Male  
Location: Illinois  
Vaccinated:2010-09-22
Onset:2010-12-26
   Days after vaccination:95
Submitted: 2011-01-19
   Days after onset:24
Entered: 2011-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUHD(10-11): INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE 10-11) / SANOFI PASTEUR U3602AA / 0 LA / IM

Administered by: Other       Purchased by: Private
Symptoms: Death, Guillain-Barre syndrome, Malaise
SMQs:, Peripheral neuropathy (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-01-06
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per patients daughter, he developed Guillain Barre Syndrome. He fell ill on 12/26/2010, was admitted to Medical Center and passed away on 1/6/2011.


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