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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1216264



Case Details

VAERS ID: 1216264 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-01-26
Onset:2021-03-28
   Days after vaccination:61
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myeloid leukaemia, Acute respiratory failure, COVID-19 pneumonia, Death, Endotracheal intubation
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Haematological malignant tumours (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: depression, hyperlipidemia
Preexisting Conditions:
Allergies: penicillin, shellfish,
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient admitted 3/28/2021 with severe COVID 19 pneumonia. She progressed to acute respiratory failure and was intubated. During her hospitalization she was diagnosed with acute myeloblastic leukemia. Her family withdrew care and she died on 4/7/2021


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1216264

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