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From the 5/7/2021 release of VAERS data (an older release, current is 11/12/2021):

This is VAERS ID 1059621

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Case Details

VAERS ID: 1059621 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-01-12
Onset:2021-01-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Chest X-ray normal, Death, Dyspnoea, Hypoxia, Lethargy, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Obesity, Diabetes Type 2, Heart Failure, Bipolar Edema, CVA, GERD, Cardiomegaly
Preexisting Conditions: See above
Allergies: Daptomycin, Penicillin, Vancomycin, Cipro, Cubicin, Rocephine
Diagnostic Lab Data: CXR - no CHF, pneumonia or effusion. No acute findings
CDC Split Type:

Write-up: 1/14/21 - Resident complained of SOB. SPO2 66% on RA, vs 105/66-96-20 T98.2 O2 administered Pox 97% Binax test revealed (+) COVID results. Resident transferred to COVID wing. Family (HCP) updated and declined transfer to hospital Resident continued with fever, hypoxia and lethargy. Family elected CMO and Hospice notified. Resident died on 1/16/2021 @ 930AM.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1059621


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