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

This is VAERS ID 1235924



Case Details

VAERS ID: 1235924 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-03-02
Onset:2021-03-30
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Sopor
SMQs:, Dementia (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   Days after onset: 3
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: Atrial fibrillation; Chronic renal insufficiency; Dilated cardiomyopathy; Vascular dementia
Allergies:
Diagnostic Lab Data:
CDC Split Type: ITMODERNATX, INC.MOD20210

Write-up: 02/04/2021; This case was received via agency (Reference number: 710323) on 14-Apr-2021 and was forwarded to Moderna on 14-Apr-2021. This regulatory authority case was reported by a physician (subsequently medically confirmed) and describes the occurrence (02/04/2021) in an 88-year-old female patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3001442) for COVID-19 vaccination. The patient''s past medical history included Dilated cardiomyopathy, Atrial fibrillation, Vascular dementia and Chronic renal insufficiency. On 02-Mar-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 30-Mar-2021, received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to .5 milliliter in total. On 30-Mar-2021, the patient experienced SOPOR (02/04/2021) (seriousness criterion death). The patient died on 02-Apr-2021. The reported cause of death was Sopor. It is unknown if an autopsy was performed. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. Action taken with mRNA-1273 in response to the events was not Applicable. Concomitant and treatment information not provided. Company Comment: Very limited information regarding the event of sopor has been provided at this time. No further information has been requested. Elderly age along with multiple comorbidities may have been contributory. Reporter did not allow further contact; Sender''s Comments: Very limited information regarding the event of sopor has been provided at this time. No further information has been requested. Elderly age along with multiple comorbidities may have been contributory.; Reported Cause(s) of Death: Sopor


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