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

This is VAERS ID 1219404

Case Details

VAERS ID: 1219404 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Ohio  
   Days after vaccination:54
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, Acute respiratory distress syndrome, COVID-19 pneumonia, Chronic kidney disease, Diabetic ketoacidosis, SARS-CoV-2 test positive
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (broad), Myocardial infarction (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), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin, Lipitor, Insulin, Nifedipine, Gabapentin, Hydroxyurea
Current Illness:
Preexisting Conditions: HTN, CAD status bypass graft x4, T2DM, peripheral and retinal neuropathy, CKD 3b, thrombocytosis, diabetic foot ulcer, remote ovarian cancer
Allergies: Sulfa
Diagnostic Lab Data: COVID-19 PCR positive 4/15
CDC Split Type:

Write-up: Pt was admitted with COVID-19 pneumonia on 4/15 that has progressed to COVID ARDS, DKA, AKI on CKD, NSTEMI

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