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From the 4/30/2021 release of VAERS data:

This is VAERS ID 986063



Case Details

VAERS ID: 986063 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Utah  
Vaccinated:2021-01-12
Onset:2021-01-16
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: Cholestyramine, Duloxetine, Fiber, Haloperidol, Hyoscyamine, Lisinopril, Lorazepam, Metoprolol, Morphine, Nystatin powder, Pepto Bismol, Seroquel, Spiriva, Symbicort, Tramadol, Tylenol, Vistaril, Zolpidem
Current Illness: COPD, CHF, Major Depressive Disorder, Anxiety, Respiratory Failure, Insomnia, OsteoArthritis, Hypertension, Irritable Bowel Syndrome, Atrial Fibrillation, COVID recovered
Preexisting Conditions: Resident was a Hospice Patient as of: 11/17/2020
Allergies: No Known Allergies
Diagnostic Lab Data: No tests/results pertaining to this incident.
CDC Split Type:

Write-up: Resident was vaccinated on 1/13/21. Resident passed away on 1/16/21


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