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

This is VAERS ID 1024325

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Case Details

VAERS ID: 1024325 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-02-03
Onset:2021-02-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: N/A
Current Illness: SHINGLES ABOUT A MONTH AGO
Preexisting Conditions: AFIB, HIGH BLOOD PRESSURE, HIGH CHOLESTEROL
Allergies: LATEX
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient passed away on February 5, 2021. There was no reaction after the shot was given, the patient''s son said the death was not related to the vaccine. The patient had a bad case of shingles about a month prior to receiving the vaccine which the son said had been hard on the patient, the patient was also 90 years old. Per the son, the patient''s doctor had wanted the patient to get the vaccine. Due to the close proximity of the date the vaccine was given and the date Patient passed away we wanted to complete the VAERS form.


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