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

This is VAERS ID 1055791



Case Details

VAERS ID: 1055791 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-01-11
Onset:2021-01-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 UN / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Illness
SMQs:

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Hives
Other Medications: Yes
Current Illness: Yes Dementia
Preexisting Conditions: Yes
Allergies: Yes
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Was given without consent from POA patient got severely sick and never recovered later passed away only live 1 month POA did not allow second vaccine to be given just wanted to report this vaccine was given illegal without POA knowledge


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1055791

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