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From the 1/22/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 962714

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Case Details

VAERS ID: 962714 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Alaska  
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Cardiac failure congestive, Chronic respiratory failure, Death
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   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: Acetaminophen suppository 650mg PRN, atropine 1% opthamlic solution, biotine moisturizing mouth solution, lorazepam concentrate 2mg/ml, milk of magnesia suspension 400mg/5ml, morphine sulfate solution 20mg/ml, zofran ODT tablet 4mg.
Current Illness: Aspiration pneumonia (dx on 12/16/2020)
Preexisting Conditions: Congestive heart failure, chronic respiratory failure, dementia, chronic mylomonocytic leukemia, chronic COPD, coronary artery disease, dysphagia.
Allergies: lisinopril, shellfish
Diagnostic Lab Data: None, no adverse events were observed relating to the COVID vaccine.
CDC Split Type:

Write-up: We do not believe that the patient''s death was an adverse event from the vaccine. Patient received COVID vaccine from Pfizer Dose #1 12/19/2020 (lot # EK5730) and Dose #2 1/7/2021 (lot # EL1284). No side effects or adverse events noted; lived in 24/7 care facility and monitored twice daily for reaction. Patient died 1/10/2021 from chronic respiratory failure and congestive heart failure after recent aspiration pneumonia requiring hospitalization. Death was anticipated and not sudden. We were told to report his death to VAERS even though his death was anticipated and not related to his vaccination.

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