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

This is VAERS ID 993112

Case Details

VAERS ID: 993112 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: California  
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Cardiac arrest, Death, Decreased appetite, Dependence on respirator, SARS-CoV-2 test positive
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin ec 81mg, xarelto 20 mg, propranolol 40 mg, Vita-B1 100mg Trazodone 50mg, Clonidine HCL 0.1 mg tablet, Divalproex 80D DR 25mg, CHLORPROMAZINE 10mg, folic acid 1 mg ,Benztropine mes 1mg, cetirizine HCL 10mg, SPIriva 18 MCG CP-handihal
Current Illness: Broken ankle
Preexisting Conditions: Mid intellectual Disabilities, Schizoaffective Disorders, Obesity, Unspecified Heart Disease, Unspecified Hypothyroidism, unspecified Allergic rhinitis
Allergies: PCN,Lactose Intol
Diagnostic Lab Data: Hospital would not share any information at all
CDC Split Type:

Write-up: she was injected, sh stopped eating and talking, the doctor watched her for 2 days. had her transported to the hospital. i was told she had tested positive for COVID 2 times once at the home and once at the hospital. with in 2 DAYS at the hospital she wa on a ventilator 2 days later she died. i talked with the rehab center and confirmed she tested negative for COVID on Dec 27th 2020 and was given the Vaccine on the 29th Dec 202 was in the hospital 4 day later, was on a ventilator 4 days after that then died a few day later as her heart stopped beating. all the while i had POA and was not contacted by Hospital staff until after they had made the next step.

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