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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 1112117

Case Details

VAERS ID: 1112117 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Utah  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Flank pain, General physical health deterioration, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Multivitamin, Allergy Med, Vit C, Ativan, B-12, Celexa, Chelated Zinc, cholecalcifefol - Vit D3, Crestor, Furosemide, Haloperidol lactate, Keflex, losartan, mangnesium oxide, morphine concentrate, potassium chloride ER, Promethazine, Seleni
Current Illness: Frontal Lobe Dementia, Muscle Weakness, Edema, weight loss
Preexisting Conditions: same as 11.
Allergies: no known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was a patient on hospice, had terminal dx of frontal lobe dementia. NP visited with patient on 03/10/2021, notable decline/flank pain, fever 101. Patient passed away on 03/12/21, Medical Director wanted this reported to VAERS d/t the vaccination was within 72hrs of the pts death.

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