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From the 11/26/2021 release of VAERS data:

This is VAERS ID 958914

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Case Details

VAERS ID: 958914 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Georgia  
Vaccinated:2020-12-30
Onset:2020-01-15
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 366
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Melatonin, Sertraline, Omeprazole, Resperidone, Depakote ER, vitamin E, multi vit, ASA, Lasix, gabapentin, potassium, Imodium, Zofran, Buspar, benztropine.
Current Illness:
Preexisting Conditions: Alzheimer''s, disorganized schizophrenia, HTN, CKD stage 3, Athritis, legal blindness, Dementia, Major Depression Disorder, Parkinson''s, GERD
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death on 1/15/2020


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