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From the 7/16/2021 release of VAERS data:

This is VAERS ID 1106733



Case Details

VAERS ID: 1106733 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-03-08
Onset:2021-03-14
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041MZ0A / 2 RA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Failure to thrive, Hypokalaemia
SMQs:, Neonatal disorders (broad), Hypokalaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   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: Potassium chloride, timolol maleate 0.5%, latanoprost 0.0005%
Current Illness: R upper lobe PNA
Preexisting Conditions: PNA, Afib with rapid response, Senile Dementia without behavioral disturbances, Hypertension, History of fall, Glaucoma, Mild protein-calorie malnutrition, lumbar degenerative disc disease, Hyperlipidemia, Hx of esophageal polyps, Dysphagia and Hiatal Hernia
Allergies: Aspirin
Diagnostic Lab Data:
CDC Split Type:

Write-up: First dose of Moderna COVID-19 vaccine given 1/7/21. Second dose of Moderna COVID-19 vaccine given 3/8/21. No adverse effects noted after vaccination. Resident was on hospice care since 2/27/2021 with poor food and fluid intake prior. Admitted to hospice with hypokalemia, failure to thrive.


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