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From the 11/26/2021 release of VAERS data:

This is VAERS ID 964724

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Case Details

VAERS ID: 964724 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Alaska  
Vaccinated:2020-12-18
Onset:2021-01-15
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   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: prozac, olanzapine, alendronate, divalproex, mirabegron, metoprolol, proair,
Current Illness: Dementia, Bipolar, COPD, HTN, Schizoaffective
Preexisting Conditions: Dementia, Bipolar, COPD, HTN, Schizoaffective
Allergies: NKDA, NKFA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Death 1-15-21


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