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From the 5/7/2021 release of VAERS data (an older release, current is 10/15/2021):

This is VAERS ID 1056845

Case Details

VAERS ID: 1056845 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Ohio  
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatinine increased, Death, General physical health deterioration, Laboratory test abnormal, Lethargy
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Retroperitoneal fibrosis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Medical records are on file at facility. Executor of the patient will grant FDA access to medical records.
Current Illness: Patient diagnosed with COVID-19 on 25 November. Mild symptoms. Tested negative within two weeks. Patient had significant Alzheimer''s disease, but not life threatening. Other co-morbid conditions that were managed through medication. Facility administered first dose of COVID-19 shortly after Christmas and second dose on 29 January.
Preexisting Conditions: See above. Recommend FDA contact facility for medical records.
Diagnostic Lab Data: Laboratory test on 26 January 2021 showed a creatinine level of 4.0 mg/dL and several other abnormal results.
CDC Split Type:

Write-up: Three days after second COVID-19 vaccine, patient became lethargic. Due to advance directive that instructed that no life saving interventions to take place, patient continued to decline and expired on 29 January 2021.

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