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From the 9/17/2021 release of VAERS data:

This is VAERS ID 926462



Case Details

VAERS ID: 926462 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-28
Onset:2021-01-04
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1042 / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Absence of immediate treatment response, Death, Hypoxia
SMQs:, Asthma/bronchospasm (broad), Lack of efficacy/effect (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 1
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: Lorazepam, pantoprazole, miralax, senna plus, carbodopa-levodopa, metoprolol, mirtazipine, quetiapine
Current Illness: dementia, Upper gastrointestinal bleed
Preexisting Conditions: Advanced dementia, Parkinson''s'' disease ,chronic kidney disease, sciatica, hyperlipidemia
Allergies: no known food or medication allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient developed hypoxia on 1/4/2021 and did not respond to maximal treatment and passed way on 1/5/2021


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