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

This is VAERS ID 926568



Case Details

VAERS ID: 926568 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-28
Onset:2020-12-30
   Days after vaccination:2
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
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 5
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: alprazolam, amlodipine, ASA, cilostazol, advair, lamotrigine, ,losartan, metoprolol,omprazole,simvastatin
Current Illness: chronic medical problems as noted below
Preexisting Conditions: dementia, peripheral vascular disease, COPD, hypertension, GERD, S/P CVA with stent of left carotid ,right common iliac and right external iliac arteries, CDK,diabetes
Allergies: clopidigrel, sulfa, vicodin
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient declined 12/30/2020 and was transferred to hospital where he did not respond to treatment and passed away 1/4/2020


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