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From the 5/7/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1033102

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Case Details

VAERS ID: 1033102 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: West Virginia  
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Chest X-ray abnormal, Chills, Cough, Death, Dyspnoea, Feeling cold, Fibrin D dimer, Fibrin D dimer increased, Interstitial lung disease, Lung infiltration, Mobility decreased, Productive cough, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin, Lipitor, Cardura, Eliquis, Finasteride, Lasix Lisinopril Meloxicam Metoprolol Multivitamin Ranitidine
Current Illness:
Preexisting Conditions: CAD, CKD
Allergies: NKA
Diagnostic Lab Data: COVID-19 Rapid PCR positive (2/5/21), D-Dimer 3.58 (2/5/21), D-Dimer 8.00 (2/7/21), chest x-ray (2/5/21) New diffuse right lung and left mid and lower lung acute infiltrates.
CDC Split Type:

Write-up: Patient received first dose of vaccine on 1/7/21 at a community Public Health clinic. On 1/29/21 he received a second dose at the community Public Health clinic. On 2/5/21, the patient presented to the ED with complaints of shortness of breath worsening over the last 2 weeks. Patient reported that he had decreased exercise capacity and increased coughing with sputum production intermittently. Patient reported that he had been feeling chilled, but no fevers. Patient was admitted and treated with Decadron and Remdesivir. Patient experienced increased oxygen requirement. Patient was a DNI and did not want to be on life support. After discussion with the patient and family, patient was moved to comfort care. passed away on 2/11/21.

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