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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1074271



Case Details

VAERS ID: 1074271 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-28
Onset:2021-03-02
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Mental status changes, Thrombocytopenia
SMQs:, Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: furosemide, lactulose, zofran, compazine, spironolactone, tenofovir, advil, on chemotherapy
Current Illness: metastatic Cholangiocarcinoma, cirrhosis
Preexisting Conditions: as above
Allergies: sulfa, cotrimazole
Diagnostic Lab Data:
CDC Split Type:

Write-up: altered mental status, acute on chronic thrombocytopenia, death


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