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From the 5/14/2021 release of VAERS data (an older release, current is 11/19/2021):

This is VAERS ID 1175454

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Case Details

VAERS ID: 1175454 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2020-12-22
Onset:2021-02-12
   Days after vaccination:52
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19 pneumonia, Condition aggravated, Death, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: COVID-19 infection
Preexisting Conditions: diabetes type 2; COPD; CHF; HTN
Allergies: unknown
Diagnostic Lab Data: Tested positive for COVID-19 by rapid antigen on 1/18/2021.
CDC Split Type:

Write-up: Died on 2/12/2021; diagnosed as a COVID-19 related death; 1st vaccine dose on 12/22/2020, 2nd vaccine dose on 1/14/2021. Hospitalized for acute respiratory failure with hypoxia and pneumonia due to COVID-19 infection.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210514&IDNUMBER=1175454


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