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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1031544



Case Details

VAERS ID: 1031544 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-02-11
Onset:2021-02-14
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Confusional state, Death, Imaging procedure, Loss of consciousness, Subdural haemorrhage
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   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: Alendronate 70mg tab Clopidogrel 75mg tab Donepezil 5mg tab Hydrochlorothiazide 12.5mg Lactobacillius tabs Levothyroxine 75mcg tab Lostartan 50mg tab Citrucel PO Metoprolol tartrate 25mg tab Pantoprazole 40mg tab Rosuvastsatin 10mg tab Tria
Current Illness: Diagnosed with subdural hemorrhage at time of incident
Preexisting Conditions: Hyperlipideia Hx stroke Hypothyroidism Gastric ulcer HTN Stress incontinence Uterine cancer Late onset Alzheimer''s Osteopenia Osteoarthritis Varicose veins in legs Venous insufficiency Adjustment disorder with anxiety
Allergies: Ibandronic acid- nausea and vomiting Sulfa- nausea and vomiting Risedronate Environmental- pollen Nitrofurantoin macro Ezetimibe-Simvastatin Codeine- anxiety Erythromycin- nausea
Diagnostic Lab Data: Imaging 2/13-2/14
CDC Split Type:

Write-up: Patient family had been noticing onset confusion for a few weeks prior to vaccine and event. Patient was taken to ED when found unconscious and died of a subdural hemorrhage a few days after vaccine clinic at retirement home.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1031544


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