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From the 1/7/2022 release of VAERS data:

This is VAERS ID 979155

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Case Details

VAERS ID: 979155 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-01-03
Onset:2021-01-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK RA / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Chills, Headache, Influenza A virus test positive, Neck pain, Vomiting
SMQs:, Acute pancreatitis (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Arthritis (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atrovastatin Calcium 80mg, Cholecalclfer0l Tablet 5000 Unit, Clopidogrel Bisulfate Tablet 75 mg, Colace Capsule 100 mg, Cyanocobalamin tablet 1000 Mcg, Famotidine Tablet 20mg, Gilmepiride Tablet 1 mg, Loperamide HCI Capsule 2Mg, Melatonin T
Current Illness:
Preexisting Conditions: Heart Disease, Polyneuropathy, Anemia and chronic Kidney disease, Type 2 Diabetes, hypotension
Allergies:
Diagnostic Lab Data: Jan 9 sent to emergency room, jan 11 tested pos for influneza A
CDC Split Type:

Write-up: Jan 3 vaccine administered, jan 4 started headaches, vomiting, pain in the back of the neck, Headaches, chills, loss of speech,


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