From the 7/23/2021 release of VAERS data:

This is VAERS ID 1041185

Case Details

VAERS ID:	1041185 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Male
Location:	Illinois

Vaccinated:	2021-01-04
Onset:	2021-01-18
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-02-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EJ1685 / 1	AR / IM

Administered by: Other Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-18
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: Levadopa; colace; lorazepam and morphine
Current Illness: COVID + 12/10/2020 recovered. Placed on Hospice care 10/2020
Preexisting Conditions: Dementia; HTN; Parkinson''s; Bladder Cancer
Allergies: No Known Allergies
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Death within 30 days

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1041185