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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1017971

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Case Details

VAERS ID: 1017971 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-06
Onset:2021-02-02
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was deceased when we came for second dose. COD unknown to pharmacy


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1017971


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