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From the 9/17/2021 release of VAERS data:

This is VAERS ID 964629

Case Details

VAERS ID: 964629 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Unknown  
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Death, Terminal state

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death - Hospice patient with metastatic CA admitted to facility and received vaccine during stay. No adverse sequelae noted from vaccine administration, but reporting as required because pt died 7 days later. Narrative: Reporting this event because patient died 7 days after receiving vaccine in the facility where he was in hospice care for metastatic cancer. Vaccine was administered by protocol without complications. The patient had been asked and denied any prior severe reaction to this vaccine or its components and gave permission to receive it. No vaccine adverse sequelae were documented after the immunization as monitored for 15 minutes nor in facility notes for 7 days after the immunization. The patient''s death was felt to be due to underlying terminal illness.

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