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From the 5/7/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 962940

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Case Details

VAERS ID: 962940 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Wisconsin  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Cold sweat, Crepitations, Death, Dyspnoea, Pallor, Productive cough
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, Digoxin, Insulin glargine, Loratadine, Simvastatin, Tamsulosin, Warfarin
Current Illness: Unknown
Preexisting Conditions: Dementia, Diabetes, Chronic A Fib, Dyslipidemia, Depression, Osteoarthritis
Allergies: Galantamine
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Pt received second dose of COVID vaccine on 01/20/2021 at 1430. At 1600 Pt developed a wet productive cough with coarse crackles. Pt ate dinner at 5 pm cough persisted. At 18:30 the nurse went to Pt''s room to give him his medications. Pt still had a cough, denied shortness of breath. Pt was in a good mood and joking with staff. Pt asked to be shaved. At 19:45 Pt was sitting in the lounge and a CNA noticed that Pt was pale/white in color and clammy. 02 Sat was 85%. Respirations were labored. Pt was placed on 4 L of 02. Increased to 5 L via face mask and 02 sat was 89-90%. Ambulance was called at unknown time. Pt arrived at Medical Center at 2120 and was pronounced dead at 2127.

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