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From the 11/12/2021 release of VAERS data:

This is VAERS ID 975206

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Case Details

VAERS ID: 975206 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Ohio  
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Chest X-ray normal, Culture urine positive, Escherichia infection, Fall, Full blood count normal, Metabolic function test normal, Urinary tract infection
SMQs:, Accidents and injuries (narrow), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: Aricept 10 mg at bedtime; Cerovite Sr, Tablet 1 tablet daily; Coreg 6.25 mg two times a day; Ferrous Sulfate 325 mg two times a day; Folidc Acid 1 mg daily; Lexapro 5 mg daily; Lisinopril Hydrochlorothizide 20-12.5 mg daily; Methimazole 5 m
Current Illness: 11/30/2020 positive for Covid-19
Preexisting Conditions: Alzheimer''s Dementio; Esential hypertension; major depressive disorder, recurrent; osteoarthritis bilateral knees; Hyperlipidemia; specified diorders of thyroid; Vit D deficiency; Impulse control disorder; Unspecified dementia with behavioral disturbance; Hypertensive retinopathy; unspecified abnormalities of gait and mobility; feeding difficulties; other dysphagia.
Allergies: No known allergies
Diagnostic Lab Data: CBC & BMP on 1/8/21 Routine labs Chest X-ray on 1/18/21- no acute pathology Urine culture 1/18/21 final results on 1/21/21 E. Coli infection
CDC Split Type:

Write-up: 1 fall after first dose on 1/8/2021 at 1930; no injuries; 4 falls after second dose on 1/14/21 at 1545, 1/15/21 at 1700, 1/21/21/at 1220 and 1/21/21 at 1330 all falls with no injuries. Started Ceftriaxone 1 GM IM daily for 5 dyas on 1/21/21 for UTI: E. Coli

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