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

This is VAERS ID 1101761

Case Details

VAERS ID: 1101761 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Florida  
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Cardiac failure congestive, Chest X-ray, Computerised tomogram head, Death, Dizziness, Dyspnoea, Echocardiogram, Hypotonia, Pulse absent, Respiratory arrest, SARS-CoV-2 test negative
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 38
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Metoprol OLSUC ER 25 mg Heart Beta Block Levoxyl (Synthroid) 175 mcg Thyroid Gabapentin 1 tablet 300 mg Neuropathy Basaglar Kwikpen 25 uinits Diabetic Therapy Fosinopril Sodium 20 mg tablet Cholestral Triamt/HTCZ 37.5 mg Blood Pressure O
Current Illness: Diabetes
Preexisting Conditions: Diabetes. Hip replacements and back surgery
Allergies: None
Diagnostic Lab Data: Echo of heart and chest X-rays on January 15. Several COVID test on January 15 and for several days after. All negative. TEE test on January 21. On February 18 echo of heart and CAT scans of brain. CAT scans again on February 21.
CDC Split Type:

Write-up: Trouble breathing. Taken to ER. Diagnosis Congestive Heart Failure. No Previous such diagnosis. Admitted for 6 days with Metropolo benign only new prescription. After 2nd shot on February 2 had follow up visits but started experiencing light headless. On February suddenly went limp with loss of pulse and breathing. Taken to Hospital ER, admitted without neurological responses. Died on February 22.

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