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

This is VAERS ID 1623782

Case Details

VAERS ID: 1623782 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Kentucky  
   Days after vaccination:179
Submitted: 0000-00-00
Entered: 2021-08-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Acute respiratory failure, Angiogram pulmonary normal, Atelectasis, COVID-19, Cardiac failure congestive, Deep vein thrombosis, Hyponatraemia, Lung opacity, Pleural effusion, Pneumonia viral, Scan with contrast normal, Septic shock, Ultrasound Doppler abnormal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Interstitial lung disease (narrow), 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 (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (narrow), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-20
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg QD Atorvastatin 20 mg QD Donepezil 5 mg QHS Metoprolol 25 mg 24H tablet QD Valsartan-HCTZ 160/12.5 mg QD
Current Illness: Unknown
Preexisting Conditions: Vascular disease Alzheimers High blood pressure
Allergies: Unknown
Diagnostic Lab Data: 8/6/2021: CTA chest pulmonary embolism with contrast: No evidence of pulmonary embolism. There are small bilateral pleural effusions and bibasilar atelectasis. Geographic areas of groundglass attenuation are noted throughout both lungs suspicious for pneumonia, congestive heart failure, or other inflammatory process. 8/10/2021 VL lower extremity bilateral venous imaging: 1: Popliteal vein DVT. 2: No sonographic evidence of left lower extremity DVT.
CDC Split Type:

Write-up: Discharge diagnosis: Acute hypoxic respiratory failure secondary to viral pneumonia in the setting of COVID-19 Acute kidney injury Septic shock Right popliteal DVT Hyponatremia

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