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

This is VAERS ID 1226135

Case Details

VAERS ID: 1226135 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Virginia  
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Acute respiratory failure, Asthma, Blood test, Chronic obstructive pulmonary disease, Computerised tomogram thorax, Death, Dyspnoea, Intensive care, Pneumonia, SARS-CoV-2 test negative, Vasculitis
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (narrow), Interstitial lung disease (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), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Vasculitis (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Immune-mediated/autoimmune disorders (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 40
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Cozaar, Zocor, Singulair EQ
Current Illness: None
Preexisting Conditions: My mother was 84 years old and had a bad reaction to her second Moderna Covid Vaccine. She knew that she had Asthma, high blood pressure and cholesterol. The next day after the 2nd Moderna shot she had chills and flu type symptoms. After that she reported that her body hurt all over which continued until she wrote her primary care doc on 3/9 about the systemic pain. She was admitted to the hospital on March 25th and died from acute respiratory failure on April 1st. The hospital said that she had asthma, COPD, Vasculitis and pneumonia. We believe that her conditions were sent into acute distress due to the second covid vaccine and vasculitis hyperreaction.
Allergies: None
Diagnostic Lab Data: Chest CT and many blood tests while in the hospital
CDC Split Type:

Write-up: My mother died in the hospital after being in the ICU for a week with severe breathing problems. Her symptoms matched that of a Covid patient but she tested negative for Covid twice (once was the 24 hour test).

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