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From the 5/14/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1054592

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Case Details

VAERS ID: 1054592 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Kentucky  
   Days after vaccination:39
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Sepsis
SMQs:, Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   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: Tylenol, ASA, Cogentin, Bisacodyl, Cetrizine, B12, Depakote, Ativan, Metformin, Multivitamin, Risperdal, Senna tabs.
Current Illness: N/A
Preexisting Conditions: 1. Mood disorder with behavioral disturbance #2 psychotic disorder #3 atypical anxiety #4 dementia with behavioral disturbance #5 cognitive communication deficit #6 impulse control disorder #7 chronic constipation #8 generalized chronic pain #9 hypomagnesia anemia #10 seborrheic dermatitis #11 B12 deficiency #12 type 2 diabetes mellitus #13 hypertension #14 anemia #15 degenerative joint disease #16 seizure disorder #17 GERD #18 hyperlipidemia #19 history of peptic ulcer disease #20 diverticulosis of the colon #21 thrombocytopenia unspecified
Allergies: NKA
Diagnostic Lab Data: Resident had been treated for sepsis a week prior, returned to hospice services after hospital readmission.
CDC Split Type:

Write-up: Resident expired on 2/24/21, under hospice care.

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