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

This is VAERS ID 1737167

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Case Details

VAERS ID: 1737167 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Georgia  
   Days after vaccination:189
Submitted: 0000-00-00
Entered: 2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, Bronchiectasis, COVID-19, Cough, Death, Pulmonary embolism, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Anaphylactic reaction (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), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-26
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Cardiovascular disease
Diagnostic Lab Data: 08/19/2021 PCR+ COVID-19 test
CDC Split Type:

Write-up: Breakthrough COVID-19 case with symptom onset 8/19/2021: Cough. Hospitalized 8/19/2021 for unknown duration. Death 8/26/2021. Vital records COD = ACUTE HYPOXIC RESPIRATORY FAILURE, COVID-19. Per vital records, COD ICD Codes include: Not yet coded ; Other Significant Conditions include: BRONCHIECHIECTASIS PULMONARY EMBOLUS; Place of death: HOSPITAL;

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