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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 940855

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Case Details

VAERS ID: 940855 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Arkansas  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: LORazepam Solution 2 MG/ML
Current Illness: Resident was a hospice patient but POA requested that she get the vaccination. Resident was already near end of life and the vaccine may not have had anything to do with her death.
Preexisting Conditions: Resident on hospice care due to end of life.
Allergies: None
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient received her vaccination on 1/12/21 administered by pharmacy*+. She expired on 1/12/21 an approximately 7:30pm. Resident did not have any adverse reactions and was a hospice patient.

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