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

This is VAERS ID 1286108

Case Details

VAERS ID: 1286108 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Illinois  
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory failure, Brain natriuretic peptide increased, Chronic obstructive pulmonary disease, Computerised tomogram thorax abnormal, Condition aggravated, Death, Hypertension, Hypomagnesaemia, Influenza virus test negative, Mental status changes, Pleural effusion, Respiratory distress, Respiratory failure, SARS-CoV-2 test negative, Urinary tract infection, Urine analysis abnormal, White blood cell count increased
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), 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), Dementia (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypertension (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: anemia, anxiety, asthma, COPD, Depression, Diabetes, Dementia, HTN
Allergies: Lisinopril
Diagnostic Lab Data: 4/8/2021 WBC: 28.34; urinalysis positive; COVID-19 Negative; Influenza Negative; BNP 183; and CT shows trace pleural effusion.
CDC Split Type:

Write-up: Hospitalization 4/8/2021-4/16/2021 with discharge home on hospice and death 4/28/2021. Admitting diagnosis: Acute respiratory distress, COPD, acute hypercapnic hypoxic respiratory failure, Hypomagnesemia; HTN; probable UTI with concerns for Severe Sepsis; Altered mental status with concerns for metabolic encephalopathy along with dementia.

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