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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1075097

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Case Details

VAERS ID: 1075097 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: New York  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatinine increased, Blood potassium increased, Blood urea increased, COVID-19, Cardiac failure congestive, Chest X-ray abnormal, Condition aggravated, Death, Decreased appetite, Eating disorder, Generalised oedema, Glomerular filtration rate decreased, Glomerular filtration rate increased, Hallucination, Oral disorder, Pleural effusion, Pneumonia, SARS-CoV-2 test positive
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Angioedema (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   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, Hydralazine, Lasix, Miralax, Protonix, senna
Current Illness: Patient received initial vaccine on 1/5/21, diagnosed with COVID-19 on 1/8/21, received monoclonal antibodies on 1/13/21, experienced CHF exacerbation during time of acute illness requiring additional diuretics, patient also experienced renal failure.
Preexisting Conditions: Alzheimer''s disease, cerebrovascular disease, ASCVD, CAD, PVD, HTN, Afib, CHF, valvular heart disease, abdominal aorta ectasia, hyperlipidemia, COPD, anemia, renal insufficiency, neuropathy, osteoporosis, DDD, scoliosis, diverticulitis, Vitamin D deficiency.
Allergies: Bisphosphonates
Diagnostic Lab Data: 1/21/21: BUN=70, Cr=2.8, EGFR=17, K=5.6 1/18/21: CXR showed small B/L pleural effusions without CHF, consistent with pneumonia.
CDC Split Type:

Write-up: Pt received initial dose on 1/5/21, diagnosed with COVID-19 on 1/8/21, treated with monoclonal antibodies on 1/13/21. Pt experienced CHF exacerbation, anasarca, and renal failure during acute illness. Pt also treated for pneumonia during this time. Pt was considered terminal status on 1/25/21. She received second COVID-19 vaccine on 2/15/21. Pt then experienced increased difficulty eating and taking medications this same day, in addition to hallucinations she was experiencing. Patient subsequently died on 2/16/21.

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