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From the 5/14/2021 release of VAERS data (an older release, current is 11/12/2021):

This is VAERS ID 993072

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Case Details

VAERS ID: 993072 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Minnesota  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Public       Purchased by: ?
Symptoms: Abdominal pain, Ascites, Blood alkaline phosphatase increased, Blood chloride decreased, Blood creatinine increased, Blood culture positive, Blood lactic acid increased, Blood potassium decreased, Blood sodium decreased, C-reactive protein increased, Carbon dioxide decreased, Death, Malaise, Omental necrosis, Ovarian necrosis, Peritoneal lavage, Platelet count decreased, Septic shock, Streptococcus test positive, Surgery, White blood cell count decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Toxic-septic shock conditions (narrow), Biliary system related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Metoprolol, Lipitor, Lisinopril, Asa,Demedex, Levimir, Jardiance, Metformin
Current Illness: None reported
Preexisting Conditions: Type 2 DM, MGUS, Cardiomyopathy with implanted Defib, Chronic heart failure
Allergies: Environmental and Magnesium succinate
Diagnostic Lab Data: WBC 1.2 with lactic acid 9.3, Plt. 113, Na 128, K 3.3, Cl 92, CO2 16, Cr 2.25, Alk phos 150, CRP 160.6. Blood cultures grew out strep A, Pt. taken to emergent surgery with no intra abdominal pathology. for sepsis found. Had massive ascites. Subsequently had a repeat wash out with necrotic ovaries/omentum noted. Never recovered and subsequently died from her illness.
CDC Split Type:

Write-up: Pt. presented to the ER with abd pain and septic shock. Pt. reported to feel ill shortly after receiving the vaccine.

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