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

This is VAERS ID 1032303



Case Details

VAERS ID: 1032303 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-07
Onset:2021-02-01
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Condition aggravated, Decreased appetite, General physical health deterioration, SARS-CoV-2 test negative
SMQs:, Guillain-Barre syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PUREED diet, Pureed texture DIET: DOUBLE PORTION @ ALL MEALS DIET: EXTRA PROTEIN ENTREE three times a day @ BREAKFAST, LUNCH AND DINNER NX: GLUCERNA 1.5 120CC three times a day for (SUPPLEMENT) WITH MEDPASS Zinc Sulfate Tablet 220 (50 Zn)
Current Illness: On monitoring for declining in condition, loss of appetite and generalized body weakness on2/1/2021
Preexisting Conditions: Hemiplegia & Hemiparesis on left non-dominant side Atherosclerotic heart Dse. Type 2 Diabetes Mellitus Cerebral Infarction PAF Thyroid Disorder Hypertension Cerebral edema GERD Occipital Neuralgia
Allergies: NKA
Diagnostic Lab Data: labs were ordered prior rto admitting to Hospice Care. NEGATIVE for COVID-19 on 2/1/2021.
CDC Split Type:

Write-up: On monitoring for declining in condition, loss of appetite and generalized body weakness on2/1/2021. Was confirmed COVID-19 positive 4/23/2020.


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