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

This is VAERS ID 1081009



Case Details

VAERS ID: 1081009 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-03-05
Onset:2021-03-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   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: combivent Respimat, Januvia 100mg,Metformin 500mg, vitamin C 100mg,Ferrous Sulfate 325mg,Famotidine 20mg,Sertraline 50mg,Carvedilol 12.5mg,Oyster shell calcium 500mg,Gabapentin 300mg,furosemide 20mg,EC Aspirin 325mg,atorvastatin 40mg,clopid
Current Illness: Cancer
Preexisting Conditions: diabetes, heart disease
Allergies: tramadol, morphine products
Diagnostic Lab Data:
CDC Split Type:

Write-up: there were no signs of adverse reaction at the time of injections and she waited 15 minutes at the site to watch for side effects. and none were evident or reported. We were notified that she passed away on Saturday, March 6.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1081009

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