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From the 5/7/2021 release of VAERS data:

This is VAERS ID 1123167



Case Details

VAERS ID: 1123167 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-03-11
Onset:2021-03-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cerebrovascular accident, Computerised tomogram, Magnetic resonance imaging
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Furosemide, Levothyroxine, Mirtazipine, omeprozole, pravastatin, thiamine,centrum,caltrate,Vitron-c
Current Illness: none
Preexisting Conditions: Chronic Back Pain with recent hospitalization, osteoporosis, anxiety disorder, Chronic heart failure, chronic atrial fib, hypothyroidism, ckd gerd
Allergies: none
Diagnostic Lab Data: ct,mri
CDC Split Type:

Write-up: Stroke


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