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

This is VAERS ID 995520

Case Details

VAERS ID: 995520 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: North Dakota  
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Angina pectoris, Back pain, Blood pH increased, Blood pressure increased, Confusional state, Discomfort, Insomnia, Pollakiuria, Urine analysis, White blood cell count increased
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Other ischaemic heart disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Clopidogrel 75 mg daily, Depakote 125 mg Twice daily, Imdur, Lexapro20 mg daily, lisinopril 10 mg daily, metoprolol succinate 25 mg daily, proscar 5mg daily, seroquel 50 mg daily, seroquel XR 150 mg daily, trazadone 50 mg daily, flomax 0.4
Current Illness: No illness at time of vaccination or one month prior.
Preexisting Conditions: Atherosclerotic heart disease, Hypertension, Borderline personality disorder, Dysthymic, Chronic ischemic heart
Allergies: NKA
Diagnostic Lab Data: Urinalysis Dipstick: Symptoms Confusion,Frequency,urgency, back pain Leukocytes 3+ Lg Ph 8.5
CDC Split Type:

Write-up: 1-12-21 Resident is complaining of heart pain. Resident blood pressure is 228/105. 1-22-21 Dx UTI 1-13-21 His nurse called MD at approximately 0645, reported to him that it was reported to this nurse that resident has not slept in 2 days and night, has an increased blood pressure, reports severe pain in lower back, and appears to be uncomfortable Resident is able to verbalize his pain and where it is at, but is unable to explain the quality of the pain or give a number on the 0/10 pain scale.

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