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

This is VAERS ID 994790

Case Details

VAERS ID: 994790 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Kentucky  
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: Prevacid, Hydrocodone, Famotidine, Combivent Respimat, Boniva, Zinc Oxide, Spiriva, Loratadine, Risperdal, Albuterol, Sertraline, Cyanocobalamin, Levothyroxine, Advair, Omega-3 fatty acids, Atorvastatin, Aspirin, Sennoside, Ergocalciferol,
Current Illness: none
Preexisting Conditions: COPD, cad, morbid obesity, depression, bipolar, hypothyroidism, hypertension and gerd.
Allergies: Ibuprofen, ketorolac, morphine,tramadol.
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident found unresponsive in room this am at approx. 9:30 am. Resident was observed eating breakfast around 8:45 am. Housekeeper reported seeing resident between breakfast and time found unresponsive. Resident had voiced no complaints. Code was initiated until EMS arrived and transported resident to hospital. Resident expired.

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