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

This is VAERS ID 1032265



Case Details

VAERS ID: 1032265 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-07
Onset:2021-01-27
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Hypotension, Oxygen saturation decreased, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PROSTAT SUGAR FREE Give 30 cc orally three times a day for SUPPLEMENT WITH MEDPASS TO PROVIDE 45G DSS 100 MG Give 1 tablet orally one time a day for (STOOL SOFTENER) HOLD FOR LBM HEALTHSHAKE 4OZ. PO three times a day for (SUPPLEMENT) BET
Current Illness: NONE
Preexisting Conditions: ANEMIA DEMENTIA HYPERLIPIDEMIA HYPERTENSION GERD
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident tested NEGATIVE for COVID-19 last 1/25/2021. She was on monitoring for desaturation and low blood pressure on Jan. 27,2021


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