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From the 11/12/2021 release of VAERS data:

This is VAERS ID 1237069

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Case Details

VAERS ID: 1237069 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-03-18
Onset:2021-04-02
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac failure, Death, Unresponsive to stimuli
SMQs:, Cardiac failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown, but did report use of blood thinner during vaccination visit.
Current Illness: None - per telephone interview with spouse
Preexisting Conditions: Unknown - none reported at vaccination visit
Allergies: NKA
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Spouse reported that patient was taken to The Hospital after unresponsive in the home on 4/2/2021. States was told that cause of death was heart failure.


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