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

This is VAERS ID 975744

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Case Details

VAERS ID: 975744 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: California  
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Full blood count abnormal, General physical health deterioration, Metabolic function test abnormal, Pyrexia, SARS-CoV-2 test negative, Tachycardia, Urinary tract infection, Urine analysis
SMQs:, Anaphylactic reaction (broad), Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), COVID-19 (broad)

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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Atorvastatin Calcium 10mg, Ceftriaxone 1GM, Famotidine, Hydrocodone-Acetaminophen 5-325mg, Levothyroxine 25mcg, Senna, ASA, Docusate
Current Illness: The resident was febrile on 1/9/2021 after receiving the Pfizer vaccine on 1/7/2021. On 1/9/2021 UA, CBC, and CMP ordered indicating she had UTI. SARS-CoV-2 testing was performed using POCT GeneXpert on 1/9/2021. No SARS-CoV-2 was detected. The resident continued to decline and on 1/15/2021 she became tachycardiac and was having trouble breathing. She was transferred to ER where she later died.
Preexisting Conditions: Dementia, Hyperlipidemia, HTN, Hypothyroidism, left femur fracture, hx of COVID-19
Allergies: NKA
Diagnostic Lab Data: UA, CBC, CMP
CDC Split Type:

Write-up: See initial report

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