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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1030893

Case Details

VAERS ID: 1030893 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Wisconsin  
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite, Fall, Food refusal, General physical health deterioration, Mobility decreased, Pyrexia, Restlessness, Urinary tract infection, Walking aid user
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Akathisia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, amlodipine, atorvastatin, clonazepam, furosemide, guaifenesin DM
Current Illness: Resident had a low grade fever day of vaccine and was not feeling well. Pharmacy stated it would be ok to have vaccine and administered in resident''s room.
Preexisting Conditions: Osteoporosis, type 2 diabetes, vitamin B deficiency, anxiety, achalasia of cardia, GERD, iron deficiency, atrial fibrillation, chronic kidney disease
Allergies: Fluoxetine and Metformin
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident had slight/slow decline in health prior to vaccine but continued to be able to walk around with walker at community. The day of the vaccine she had a fever. 2 days after vaccine resident did not get out of bed all day and refused to eat. She had small amounts of orange juice as her blood sugar level was low due to not eating. Resident was diagnosed with a UTI and began an oral antibiotic. 3 days after and on day 5 after vaccine resident began feeling weak and had a fall on each day. The following day again resident spent the day in bed. The next day she was quite restless, was on the edge of her bed attempting to self transfer often throughout the day. Resident continued to be restless on the 10th of Feb, had further decline on the 11th of Feb. Resident passed away early the AM of Feb. 12th.

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