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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1017176

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Case Details

VAERS ID: 1017176 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Missouri  
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Acute kidney injury, Atrial fibrillation, Blood pressure decreased, Cardiac failure congestive, Cardiomyopathy, Death, Laboratory test abnormal, Multiple organ dysfunction syndrome, Oedema peripheral, Oxygen saturation decreased, Urinary incontinence
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Apixaban, Aspirin, Atorvastatin, Budesonide, Carvedilol, Docusate, Ferrous Gluconate, Furosemide, Lisinopril, Omperazole, Tiotropium Bromide inhaler, Amlodipine, Tylenol, Albuterol, Naproxen
Current Illness: Hypertension, Chronic ischemic heart disease, COPD, Atrial Fibrillation, Cardiomyopathy, Edema, Dementia, Anemia, Hyperlipidemia
Preexisting Conditions: COPD, Chronic ischemic heart disease, A fib, Hypertension
Allergies: NKA, NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had Covid-19 in October of 2020. He recovered. He received the vaccination on 12/30/2020 with no complaints. On 01-05-2021 it was noted to he was incontinent of urine and bilateral lower extremity edema. Lab work was completed showed acute kidney injury. He had decreased blood pressure and oxygen saturations on 01-06-2021 He was admitted to the hospital with rapid progression of symptoms and suggested multi-system failure. He had a long cardiac history. On 01-14-2021 he passed away with a diagnosis of Cardiomyopathic CHF, A.Fib contributory.

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