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From the 5/7/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1123805

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Case Details

VAERS ID: 1123805 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Texas  
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, Asthenia, Chills, Confusional state, Death, Hypoxia, Pyrexia, SARS-CoV-2 antibody test positive, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), 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: 2021-02-24
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: allopurinol (ZYLOPRIM) 100 MG qd aspirin (Aspir-Low) 81 MG qd B complex-vitamin C-folic acid (NEPHRO-VITE) 0.8 MG qd cyanocobalamin (VITAMIN B-12) 1000 MCG qd folic acid (FOLVITE) 1 MG qd furosemide (LASIX) 40 MG bid insulin degludec 30 Uni
Current Illness: ESRD s/p renal transplant 2010, DM, HTN, CAD, HLD, GERD, Hypothyroidism
Preexisting Conditions: ESRD s/p renal transplant 2010, DM, HTN, CAD, HLD, GERD, Hypothyroidism
Allergies: NKDA
Diagnostic Lab Data: COVID 19 PCR + 2/17/2021 COVID antibody (total) + 2/20/2021
CDC Split Type:

Write-up: Admitted on 2/17/2021 with acute respiratory failure with marked hypoxia. Noted to have fever & chills, weakness and acute confusion ~ 3 days prior to admission. Placed on NIPPV, steroids, convalescent plasma and antibiotics. Patient died 2/24/2021

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