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

This is VAERS ID 995460



Case Details

VAERS ID: 995460 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: New Hampshire  
Vaccinated:2021-01-07
Onset:2021-01-16
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Levothyroxine Sodium Tablet 50 MCG daily Cholecalciferol Tablet 2000 UNIT daily Metoclopramide HCl Tablet 5 MG 4 times a day Tylenol Tablet 325 MG as needed Q4hrs Senokot S Tablet 8.6-50 MG (Sennosides-Docusate Sodium) 2 tabs daily Atorv
Current Illness: N/A Covid positive on 1/10 Hospitalized 1/16 Deceased 1/25
Preexisting Conditions: HEMIPLEGIA AND HEMIPARESIS FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE AFFECTING RIGHT DOMINANT SIDE (I69.951) WEAKNESS (R53.1) UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE (F03.90) PNEUMONIA, UNSPECIFIED ORGANISM (J18.9) UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY (R26.9) HEART FAILURE, UNSPECIFIED (I50.9) CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED (J44.9) ENCOUNTER FOR SURGICAL AFTERCARE FOLLOWING SURGERY ON THE DIGESTIVE SYSTEM (Z48.815) ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (I25.10) ESSENTIAL (PRIMARY) HYPERTENSION (I10) ACUTE EMBOLISM AND THROMBOSIS OF DEEP VEINS OF RIGHT UPPER EXTREMITY (I82.621) APHASIA FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE (I69.920) DYSPHAGIA FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE (I69.991) FLUID OVERLOAD, UNSPECIFIED (E87.70) DYSPHAGIA, OROPHARYNGEAL PHASE (R13.12) COVID-19 (U07.1) SPONDYLOLYSIS, CERVICAL REGION (M43.02) HYPERLIPIDEMIA, UNSPECIFIED (E78.5) PNEUMONIA, UNSPECIFIED ORGANISM (J18.9) VITAMIN D DEFICIENCY, UNSPECIFIED (E55.9) CELLULITIS OF RIGHT UPPER LIMB (L03.113) ENCOUNTER FOR ATTENTION TO COLOSTOMY (Z43.3) INCONTINENCE WITHOUT SENSORY AWARENESS (N39.42) OTHER PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE (I26.99) OTHER SPECIFIED SOFT TISSUE DISORDERS (M79.89) OTHER SPECIFIED SYMPTOMS AND SIGNS INVOLVING THE DIGESTIVE SYSTEM AND ABDOMEN (R19.8) VASCULAR DISORDER OF INTESTINE, UNSPECIFIED (K55.9) DYSPHAGIA, UNSPECIFIED (R13.10) HYPOKALEMIA (E87.6) GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS (K21.9) OTHER DYSPHAGIA (R13.19) VERTEBRO-BASILAR ARTERY SYNDROME (G45.0) ADJUSTMENT DISORDER WITH MIXED DISTURBANCE OF EMOTIONS AND CONDUCT (F43.25) BENIGN NEOPLASM OF COLON, UNSPECIFIED (D12.6) CEREBROVASCULAR DISEASE, UNSPECIFIED (I67.9) DISORDER OF KIDNEY AND URETER, UNSPECIFIED (N28.9) HEMATEMESIS (K92.0) HYPOTHYROIDISM, UNSPECIFIED (E03.9) LONG TERM (CURRENT) USE OF ANTICOAGULANTS (Z79.01) METABOLIC ENCEPHALOPATHY (G93.41) OTHER HYPERLIPIDEMIA (E78.4) OTHER SPECIFIED MENTAL DISORDERS DUE TO KNOWN PHYSIOLOGICAL CONDITION (F06.8) PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS AND EMBOLISM (Z86.718) PERSONAL HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIA), AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS (Z86.73) RESPIRATORY FAILURE, UNSPECIFIED, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA (J96.90) DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED (R26.2) PNEUMONIA, UNSPECIFIED ORGANISM (J18.9)
Allergies: Vancomycin
Diagnostic Lab Data: Positive Covid swab on 1/10
CDC Split Type:

Write-up: Vaccine-1/7 Covid positive-1/10 Hospitalized-1/17 Deceased-1/25


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