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

This is VAERS ID 959272

Case Details

VAERS ID: 959272 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Kansas  
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: uncertain illness, however, patient was on Hospice.
Preexisting Conditions: uncertain illness, however, patient was on Hospice. We are not his primary care providers, just provided the vaccine.
Allergies: none
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient died 4 days after immunization. Probably unrelated to immunization, as patient has been in poor health and was receiving hospice services. I have no details related to his illness or symptoms. Daughter is the HIPAA/emergency contact and will have all the information needed.

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