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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1454790

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Case Details

VAERS ID: 1454790 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: South Dakota  
   Days after vaccination:56
Submitted: 0000-00-00
Entered: 2021-07-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Death, Multiple organ dysfunction syndrome, Pyrexia, Respiratory distress, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (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), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Patient in overall poor health and was in care at time of hospitalization and subsequent death; she was in a facility.
Preexisting Conditions: Patient in care at time of hospitalization and subsequent death; she was in a facility. Patient has history of congestive heart failure, Type 2 diabetes, morbid obesity, diastolic heart failure with preserved ejection fraction, previous Cerebrovascular Accident.
Allergies: HMG-COA-R Inhibitors; adhesives; Morphine Sulfate
Diagnostic Lab Data: Patient tested positive for COVID-19 on 03/29/2021 (both antigen and PCR) despite being fully vaccinated.
CDC Split Type:

Write-up: Patient tested positive for COVID-19 on 03/29/2021 via both antigen and PCR despite being fully vaccinated. She was subsequently hospitalized and then died on 03/30/2021. Symptom onset for COVID-19 was 03/23/2021, with symptoms of fever (101.8) and respiratory distress which required an increase in oxygen. Per the death certificate, causes of death are as follows: Part 1: Cause of Death: A. Multi organ failure B. COVID-19 infection Part 2: Other Significant Conditions: Congestive Heart Failure, Diastolic Heart Failure with Preserved Ejection, history of cerebrovascular accident, diabetes mellitus type 2, and morbid obesity

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