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

This is VAERS ID 966856

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Case Details

VAERS ID: 966856 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Kentucky  
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Bacterial test positive, Blood bilirubin increased, Blood creatinine increased, Blood glucose normal, Blood potassium decreased, Blood sodium increased, Blood urea increased, Chest X-ray normal, Computerised tomogram head abnormal, Computerised tomogram thorax normal, Coronavirus infection, Culture urine negative, Death, Decreased appetite, Fluid intake reduced, General physical health deterioration, Haematoma, Haemoglobin decreased, Hyporesponsive to stimuli, Nitrite urine absent, Platelet count normal, SARS-CoV-2 test positive, White blood cell count increased, White blood cells urine positive
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Biliary system related investigations, signs and symptoms (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Covid outbreak in the facility tested two week before negative.
Current Illness: unk
Preexisting Conditions: renal AND Alzheimer''s
Allergies: unk
Diagnostic Lab Data: 1/8: White blood cell count 11.6, hemoglobin 12.2, platelets 369. Sodium is 165, potassium 3.2. BUN/creatinine creatinine are 48 and 1.2. Bilirubin is 1.6. Glucose 127. Urinalysis has 25 leukocytes, negative nitrites, 10-15 white blood cells, 1+ bacteria. Chest x-ray shows no acute cardiopulmonary disease. CT scan of the head shows a tiny left frontal scalp hematoma, with nothing else acute. - 1/9: White blood cell count is 13.5, hemoglobin 12.1. Sodium is 168, potassium 3.4. BUN/creatinine are 47 and 1.3, glucose 145. - 1/10: WBC 15.5, Hgb 10.6. Plt 268. Na 169, K 4.0, Glucose 174. BUN/Cr 38/1.1. Urine culture showed NO GROWTH. - 1/11: WBC: 12.7 HGB: 10.2 PLT: 223 SODIUM: 164 POTASSIUM: 3.9 GLUCOSE: 172 BUN: 32 CREATININE: 1.2 SArs-cor-2 RDRp gen detected 1/4/2021 ( NEDS ID 7797449)
CDC Split Type:

Write-up: Patient is a 90-year-old female. She is a nursing home resident with and ongoing COVID 19 outbreak occurring . She has been diagnosed with corona virus on 1/4/21. She apparently has not eaten or drank anything in about a week. She was being hydrated at the nursing home with normal saline, but has failed to improve. She was sent to the ER and was admitted on 1/8/21 to hospital At no time during the hospital stay has she been more than minimal responsive. She need O2 for Comfort but on CXR and CT cardiopulmonary imagining was clear. Discharge note stated that he was requiring supplemental oxygen, but her chest x-ray on admission actually showed no acute cardiopulmonary disease. She was diagnosed with COVID-19 on 1/4/21. Most likely, this disease set her level of function back to the point that she was no longer eating and drinking, and she just overall rapidly declined after that. There was no evidence of an actual COVID pneumonia or pneumonitis. On 1/12/2021 family made patient a DNR and IVF were stopped and switched to comforted care. Patient expired 1/13/21

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