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From the 5/7/2021 release of VAERS data (an older release, current is 1/7/2022):

This is VAERS ID 1017367

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Case Details

VAERS ID: 1017367 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-01-05
Onset:2021-01-14
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Individual was healthy prior to vaccination.
Preexisting Conditions: Individual had Alzheimer''s disease.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Individual collapsed 9 days post-vaccination with no known reason. Despite being healthy prior to vaccination, individual''s condition deteriorated rapidly. Individual passed away on 1-17-2021.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1017367


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