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From the 11/12/2021 release of VAERS data:

This is VAERS ID 1046915

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Case Details

VAERS ID: 1046915 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Iowa  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood pressure immeasurable, Body temperature increased, Cardio-respiratory arrest, Chills, Death, Dyspnoea, Feeling abnormal, Hyperhidrosis, Pain, Pallor, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   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: Humalog Insulin Sliding scale 4 times daily, Acidophilus Probiotic Blend CP 1 capsule 3 times daily with meals, Amiodarone 200mg 1 tab twice daily, Aspirin 81mg 1 tab once daily, Atorvastatin 40mg 1 tab at bedtime, Bumetanide 0.5mg 1/2 tab
Current Illness:
Preexisting Conditions: Above the knee amputation of left lower extremity, Coronar Artery Disease, Clotted Dialysis access, Previous COVID-19 Virus Infection 11/2/20. Diabetes, Dialysis patient, End Stage Renal Disease, Gastric Bypass status for obesity, Hypertension, Non healing wound of amputation stump, Polyneuropathy, Pneumonia secondary to COVID infection, Atrial Fibrillation, Hx of stroke,
Allergies: Tramadol (vomiting, nausea), Tape (Rash, Itching), Bee stings (anaphylactic reaction), Betadine (rash, Itching), Wasps (anaphylactic reaction), Clonidine( vomiting), Isosorbide (vomiting)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident received the 2nd dose of the Covid vaccine approximately around 1105 by pharmacy through the pharmacy LTC partnership vaccination program. Resident had no adverse effects until around 8:00 pm she began complaining of body aches, and chills, Tylenol was given at this time. Around 9:30pm resident was sleeping in bed. Around 12:00 am the CNA called nurse into room to assess resident as the resident stated she did not feel good. Temperature at that time was 102.2, and vomiting. RN came to assess @ 1220 am She was noted to be vomiting, diaphoretic, pale and having trouble breathing. Temp was 97.3 after vomting, Pulse 53, Resp 20, o2 sats were 40-45%, unable to obtain Blood pressure, Applied 5 L of oxygen at this time and had LPN call 911 immediately. Resident was repsonsive and able to follow staff members instructions but was only answering yes or no simple questions at the time time of assessment. Paramedics arrived at 0040 and resident was sent to Hospital. @ 0130 ER nurse called to nursing facility to notify resident had coded in the ER and passed away @ 0110.

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