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

This is VAERS ID 1088367



Case Details

VAERS ID: 1088367 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-04
Onset:2021-02-24
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Arteriosclerosis
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   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: Synthroid, Prilosec, Imdur, ASA, Valium, Lipitor, Toprol, Vitamin d3 10,000 Units, Remeron, Restoril, Fosamax, Norvasc, Iron vitamin, Buspar, Seroquel
Current Illness:
Preexisting Conditions: Hypothyroidism, Diabetes, Osteoporosis, Chronic Ischemic Heart Disease, Bedridden
Allergies: None were reported
Diagnostic Lab Data:
CDC Split Type: PR-53-21

Write-up: Person of contact spent around 10 minutes in the room, spoke with the resident, left the room. When the caregiver came into the room with the resident lunch the resident was without vital signs. Dxn: Atherosclerotic Heart Diseases


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1088367

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