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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1053788



Case Details

VAERS ID: 1053788 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-02
Onset:2021-02-15
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: None reported
Current Illness: None reported
Preexisting Conditions: None reported
Allergies: None reported
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Received call that patient is now deceased


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1053788

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