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From the 4/30/2021 release of VAERS data:

This is VAERS ID 986869



Case Details

VAERS ID: 986869 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-03
Onset:2021-01-10
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ELI284 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Respiratory distress
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Prednisone, Miralax, Labetalol, Gas-X, Gabapentin, Folic Acid, Fluconazole, Famotidine, Eliquis, Crestor, Bactrim
Current Illness: Pembro associated pneumonitis and nuronal inflammation, Candida Esophagitis
Preexisting Conditions: HTN, MVP/Mod MR, Prior Renal Ca s/p R nephrectomy, Active Lung Ca (Prior lobectomy/SRT on pembrolizumab)
Allergies: NKA
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient noted with respiratory distress on 1/10/2021, transferred to hospital via 911.


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