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From the 11/19/2021 release of VAERS data:

This is VAERS ID 962827

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Case Details

VAERS ID: 962827 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-14
Onset:2021-01-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite, Fatigue, General physical health deterioration, Hypoglycaemia, Lactic acidosis
SMQs:, Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Guillain-Barre syndrome (broad), Hypoglycaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 0
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:
Current Illness:
Preexisting Conditions: chronic combined CHF, diabetes mellitus, HTN, hyperlipidemia, CKD stage 3
Allergies: ATORVASTATIN; CODEINE; DOXY
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted 1/14/21: Patient is an elderly 93-year-old female with multiple medical problems including chronic combined CHF, P 80, diabetes mellitus, HTN, hyperlipidemia, CKD stage 3, has been complaining of generalized weakness, fatigue, decreased appetite for the past few days. She had an outpatient COVID-19 vaccine earlier today. Within 2 hr of admitting the patient to the hospital, condition clinically deteriorated. Patient elected to be DNR/DNI while in the ED. Patient was pronounced dead at 10:30 p.m. earlier today. Preliminary cause of death: Hypoglycemia induced lactic acidosis.


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