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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 965565

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Case Details

VAERS ID: 965565 (history)  
Form: Version 1.0  
Age: 84.0  
Sex: Male  
Location: Nebraska  
   Days after vaccination:10
Submitted: 2021-01-19
   Days after onset:14
Entered: 2021-01-22
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Other
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   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:
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative: Please note that patient is a hospice patient. Death occurred 10 days post vaccination. Providers do not believe that there was a correlation. Facility requires that we reports all death even if we suspect no correlation between death and vaccine. Symptoms: & death

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