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From the 5/7/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 974172



Case Details

VAERS ID: 974172 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-01-24
Onset:2021-01-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283-WA / 1 LA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: guaiFENesin, aspirin, celexa, Buprenorphine, zinc, vitamin D, voltaren gel, miralax, hydralazine, ascorbic acid, coreg, tramadol, metolazone, melatonin, potassium, gabapentin, senna, magnesium, ocuvite, losartan potassium, doss, vitamin B1
Current Illness: COVID-19 diagnosis 12/29/2020, pneumonia, CHF, depression, rheumatoid arthritis and anemia.
Preexisting Conditions: CHF, acute on chronic anemia, pulmonary hypertension, chronic pain, chronic kidney disease stage 3,
Allergies: lisinopril
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident passed away 1/25/2021 at 1048pm after the vaccine was given on 1/24/2021. Resident had been being monitored but death was not expected.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=974172

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