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

This is VAERS ID 1366598

Case Details

VAERS ID: 1366598 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Minnesota  
   Days after vaccination:46
Submitted: 0000-00-00
Entered: 2021-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Blood loss anaemia, Blood test, Computerised tomogram intestine, Death, Electrocauterisation, Endoscopy gastrointestinal abnormal, Haemoglobin decreased, Internal haemorrhage, Intestinal mucosal tear, Rectal examination, Upper gastrointestinal haemorrhage
SMQs:, Haematopoietic erythropenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific inflammation (broad), Ischaemic colitis (broad), Noninfectious diarrhoea (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-22
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Furosemide, acidophilus, allopurinol, ferrous sulfate, latanaprost, levothyroxine, magnesium oxide, multivitamin, potassium chloride. ascorbic acid. B complex, diltiazem, metoprolol succinate, vitamin D-3, warfarin
Current Illness: Congestive heart failure Atrial fibrillation Lymphadema
Preexisting Conditions: Congestive heart failure Atrial fibrillation Previous replacement of aortic valve
Allergies: Erythromycin
Diagnostic Lab Data: 05/12/21 lab (blood) tests hemoglobin 5.6 and rectal exam to determine source of bleeding. CT Scan, Endoscopy resulting in cauterization of tear in lower intestine. Unable to view all tears. Next blood test shows hemoglobin 5.2.
CDC Split Type:

Write-up: Onset acute blood loss due to internal bleeding on approximately 05/09/21, upper GI bleeding and anemia. Hemoglobin dropped to 5.2 resulting in death. Hospitalization on 05/12/21 discharged to Hospice Care 05/15/21 loss of life on 05/22/21.

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