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From the 5/7/2021 release of VAERS data (an older release, current is 1/7/2022):

This is VAERS ID 954812

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Case Details

VAERS ID: 954812 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: New York  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain upper, Cardiac arrest, Chest discomfort, Headache, Heart rate irregular, Nausea, Pulseless electrical activity, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: apixaban, levothyroxine, prednisone, diltiazem, (cont page 2)
Current Illness: Unknown
Preexisting Conditions: non stentable distal occlusive disease, coronary heart disease, stroke, heart failure, diabetes mellitus, (cont. p 2)
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: She had the first dose of Pfizer vaccine at the Campus on Friday 1/15 at 4:30 pm. After the vaccine, she had no new symptoms or signs of vaccine reaction and MD friend reports that he checked her pulse which was not elevated from baseline. On 1/16, she awakened and continued to feel at her recent baseline. However, in the early afternoon, she complained of headache, nausea/epigastric pain, and chest heaviness. These apparently were not unusual symptoms for her to feel intermittently. Per her niece, who has a home O2 sat device, her 02 sat that morning was 97 with a HR of 87 irregularly irregular. She was afebrile. (continue on page 2)

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