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

This is VAERS ID 1075388



Case Details

VAERS ID: 1075388 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-02-15
Onset:2021-02-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood lactic acid decreased, Burning sensation, C-reactive protein normal, Cardio-respiratory arrest, Computerised tomogram head normal, Death, Fatigue, Herpes zoster, Hypoaesthesia, Loss of consciousness, Metabolic function test normal, Myalgia, Neck pain, Pain in extremity, Pyrexia, Rash pruritic, Resuscitation, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (narrow), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (narrow), Arthritis (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypoglycaemia (broad), Opportunistic infections (broad), Sexual dysfunction (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, allopurinol, amlodipine, ezetimibe, furosemide, latanoprost, lisinopril, loratadine, mesalamine, metformin, metoprolol, mometasone, multivitamin, omeprazole,
Current Illness: none
Preexisting Conditions: CLL, Essential hypertension, NIDMM, hyperlipidemia, diverticulosis,
Allergies: Dust, Penicillian
Diagnostic Lab Data: CT of head - neg CBC - WBC 24.8 - consistent with CLL CMP - WNL CRP - 0.9 Lact Acid - 1.43 Labs were not collected on 2nd visit
CDC Split Type:

Write-up: The day after the shot she developed fever for 2 days as high as 101. She developed a pruritic burning rash to posterior right leg extending down the lateral lower leg. She had fatigue and myalgias. Diagnosed with shingles on 2/23. and informed to not receive the 2nd vaccine. She presented to the Emergency room on 2/27 with fatigue, numbness right side of the face, no reports of shortness of breath or chest pain. Ambulated in to ER. After her work up she was discharged home - she present back to the ER within 30 minutes. PTA arrival at the ER for the 2nd time - she complained of left neck and arm pain - then went unconscious. She arrived to the ER in full arrest - pronounced deceased after resuscitation efforts were not effective


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