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

This is VAERS ID 1032279



Case Details

VAERS ID: 1032279 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-07
Onset:2021-01-29
   Days after vaccination:22
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: General physical health deterioration, SARS-CoV-2 test negative
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: Vitamin C Tablet 500 MG (Ascorbic Acid) Give 1 tablet orally two times a day for (SUPPLEME NX: ICE CREAM two times a day @ LUNCH AND DINNER HEALTHSHAKE 4OZ. PO three times a day for SUPPLEMENT BETWEEN MEALS ARTIFICIAL TEARS Instill 1 dr
Current Illness: NONE
Preexisting Conditions: ATHEROSCLEROTIC HEART DSE DEMENTIA HLD
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident tested NEGATIVE for COVID-19 on 1/25/2021. She was on monitoring for declining in condition on 1/29/2021.


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