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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1000752

Case Details

VAERS ID: 1000752 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Indiana  
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Feeling abnormal, Nasopharyngitis, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: citalopram, atorvastatin, felodipine, avalide, metoprolol, omeprazole
Current Illness: none that I''m aware of
Preexisting Conditions: aortic atherosclerosis, essential hypertension, depression, type 2 diabetes with stage 4 chronic kidney disease
Allergies: penicillin, procain
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt son, reports patient passed away on 2/1/21 in the early hours. Pt wife, told Pt''s son that patient started feeling "bad" with common cold like symptoms on 1/31/21, had a temp of 99.0. Pt''s wife went to take a shower, when she got out patient was unresponsive. She called EMS, they pronounced patient deceased upon arrival. Pt''s son also reports patient and Pt''s wife both had their 1st COVID-19 vaccine 13 days prior. He was told by EMT on sight to notify the facility where they received their vaccines. He did contact them and was told to notify PCP.

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