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

This is VAERS ID 1031629



Case Details

VAERS ID: 1031629 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-02-08
Onset:2021-02-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 7+ RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Death, Diet refusal, Fluid intake reduced, General physical health deterioration, Haematemesis, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, Fentanyl Transdermal, Gabapentin, Lorazepam, Metoprolol, Morphine, Omeprazole, ONdansetron, Miralax, Tylenol, Ibuprofen
Current Illness: Compression fracture
Preexisting Conditions: Abdominal Aortic Aneurysm, Constipation, Malnutrition, Peripheral Vascular Disease
Allergies: GI upset from Fentanyl, No other food or drug allergies
Diagnostic Lab Data: No lab or other tests performed at request of family as patient was on hospice palliative care.
CDC Split Type:

Write-up: Patient became nauseated about 10 minutes after vaccine administered, this subsided but returned several hours after the vaccine was given. She continued with intractable nausea and vomiting for about 24 hours. This patient was enrolled in hospice and she continued to decline and refused to eat or drink. She was taking Ibuprofen due to intractable back pain. Her emesis was coffee ground color. After this her condition continued to decline until her death


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1031629

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