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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1259591

Case Details

VAERS ID: 1259591 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Illinois  
   Days after vaccination:77
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Atrial fibrillation, Cardiac failure congestive, Condition aggravated, Death, Electrocardiogram abnormal, General physical health deterioration, Laboratory test, Myocardial depression, Respiratory depression, Urine analysis
SMQs:, Cardiac failure (narrow), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (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), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-23
   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: warfarin, alendronate, atorvastatin, losartan, metolazone, famotidine, norvasc, KCl, furosemide
Current Illness: Pruritis
Preexisting Conditions: arthritis, dementia, resp failure, heart failure, a fib, hyperlipidemia, cellulitis.
Allergies: morphine, shellfish, shrimp, allergenic food extract shrimp
Diagnostic Lab Data: UA, EKG, labs. Afib w/RVR, CHF exacerbation
CDC Split Type:

Write-up: Congestive Heart Failure decline, AFib w/RVR, hospitalization, Respiratory decline, Cardiac decline, possible UTI, Hospice Care, continued decline, expired.

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