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

This is VAERS ID 1237427

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Case Details

VAERS ID: 1237427 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: North Carolina  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Influenza like illness, Laboratory test abnormal, Pain in extremity
SMQs:, Retroperitoneal fibrosis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Humera, multi-vitamin, prednisone, iron
Current Illness:
Preexisting Conditions: COPD, Rheumatoid arthritis
Allergies: Adavan
Diagnostic Lab Data: Patient had just received positive lab results back from primary care physician visit prior to vaccine.
CDC Split Type:

Write-up: Arm soreness 1-3 days post vaccine flu like symptoms 4-7 days post vaccine Severe back pain 4-10 days post vaccine Death 11 days post vaccine

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