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

This is VAERS ID 1361481

Case Details

VAERS ID: 1361481 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: New York  
Submitted: 0000-00-00
Entered: 2021-05-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: ?
Symptoms: Bilevel positive airway pressure, Blood gases, Blood test, Computerised tomogram, Condition aggravated, Death, Dizziness, Echocardiogram, Fatigue, Hypercapnia, Hypopnoea, Oxygen saturation decreased, Respiratory distress, Respiratory gas exchange disorder, X-ray
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (narrow), Vestibular disorders (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-21
   Days after onset: 50
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None known
Preexisting Conditions: Dementia (diagnostic studies in May 2021 suggest vascular)
Allergies: None
Diagnostic Lab Data: Blood tests, including ABGs, X-rays, CT scans, echocardiograms, clinical evaluations, etc., all from hospital stay from 5/6/2021 to 5/21/2021. "Baseline" medical tests (clinical exam and echocardiogram) from January 2021.
CDC Split Type:

Write-up: Rapid decline in ability to perform respiratory gas exchange and build up of carbon dioxide in the blood to life-threatening levels, ultimately leading to death. Rapid decline began about 2 weeks after receiving vaccine. Death would likely have occurred on 5/6/2021 or 5/7/2021 but for hospital intervention via use of a BiPAP machine. Patient had been exhibiting more mild, non-COVID respiratory distress for some time, back to at least late 2020, and likely at even lower levels for several years prior. Signs and symptoms included shallow breathing, extreme fatigue, difficulty or inability to lie down, occasional lightheadedness, etc. Oxygen saturation levels in April, as measured by a pulse oximeter, ranged from about 87%-96%. On May 6, it measured 65% just prior to ER visit.

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