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

This is VAERS ID 1116373



Case Details

VAERS ID: 1116373 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Death
SMQs:, Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No adverse event history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; so weak she was no longer able to use her walker and declined steadily each daythereafter; A spontaneous report was received from a consumer concerning a 88-year-old female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced being so weak she was no longer able to use her walker and declined steadily each day thereafter (asthenia) and passed away (death). The patient''s medical history was not provided. Concomitant product use was not provided by the reporter. The patient received their first of two planned doses of mRNA-1273 (Batch number not provided) on an unspecified date. On an unspecified date, approximately 15 days prior to the onset of the symptoms, the patient received their second of two planned doses of mRNA-1273 (Batch number not provided) intramuscularly for prophylaxis of COVID-19 infection. On an unspecified date, two days after their second dose of the vaccine, the patient was so weak that she was no longer able to use her walker and declined steadily each day thereafter. On an unspecified date, 17 days after their second dose of the vaccine, the patient passed away. Treatment information was not provided. The outcome of the event, asthenia, was unknown. The outcome of the event, passed away (death), was fatal. The cause of death was reported as unknown. Plans for an autopsy were not provided.; Reporter''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


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