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From the 5/14/2021 release of VAERS data (an older release, current is 10/15/2021):

This is VAERS ID 1017675

Case Details

VAERS ID: 1017675 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Massachusetts  
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: capsacin pad, Ativan liquidMorphine Sulfate 20mg/ml
Current Illness: COPD, Diabetes Mellitus type 2
Preexisting Conditions: Nalignant neoplasm of cecum, COVID positive 10/2020, cerebral infarction,athersclerotic heart disease, heart failure, AV block
Allergies: sulfa antibiotics
Diagnostic Lab Data:
CDC Split Type:

Write-up: This 96 year old resident was diagnosed with COVID on 10/28/2020. She has a significant, complicated medical history and did not return to her pre-infection level of health. She began declining in early January and was made care and comfort measures only on 1/2/2021. Most of her medications were d/c''d except for those that provided comfort. No obvious reaction to the vaccine was seen and we do not suspect that her death was vaccine related, however we were directed by Dept of Epidemiology to report her death as it was within one week of receiving the vaccine.

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