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

This is VAERS ID 1223371

Case Details

VAERS ID: 1223371 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Illinois  
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Computerised tomogram abnormal, Death, Fibrin D dimer increased, Pneumocystis jirovecii pneumonia, Pulmonary embolism
SMQs:, Haemorrhage laboratory terms (broad), Embolic and thrombotic events, venous (narrow), Infective pneumonia (narrow), Opportunistic infections (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-23
   Days after onset: 25
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Vitamin C 4000mg, losartan 100mg, Anastrazole 1mg, prednisone 80mg, rituximab infusion, famotidine 20mg, amlodipine 5mg, vitamin D3 1000iu
Current Illness: Autoimmune Hemolytic Anemia, diagnosed with stage 1 breast cancer January 2021,
Preexisting Conditions: Hypertension
Allergies: None
Diagnostic Lab Data: ddimer positive test then CT scan to verify clots in her lungs
CDC Split Type:

Write-up: Patients First dose 01/13/2021 and second dose of Moderna Covid 19 vaccine was administered on February 11th. Patient developed pulmonary embolism in both lungs and hospitalized February 25th. Patient later developed PCP Pneumonia and died March 23rd.

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