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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1246484

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Case Details

VAERS ID: 1246484 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-04-16
Onset:2021-04-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B21-2A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Furosemide 20mg , Losartan Potassium 100mg, Bayer COntour Test in Vitro Strip, Vit, D3, Atorvastatin Calcium 10mg, Glipizide ER 2.5mg, B complex, one touch delica lancets 33g, multivitamin, amlodipine besylate 10mg, mtroprolol tartrate 25mg
Current Illness:
Preexisting Conditions: urge incontinence, stress, ,menopausal and postmenopausal disorder, postmenopausal vag. bleeding, fall risk, cirrhosis, mobitz type 2 second degree av block, adenocarcinoma of endometrium, right bundle branch block, preop cardiovascular eval, thrombocytopenia, pacemaker, acute kidney failure,, atrioventricular block , 2nd degree, anemia, chronic deep venous thrombosis, venous stasis, hx of DVT, pulmonary embolism, CKD stage 3, wrist tenderness, cataract, vit. D deficiency, morbid obesity, hypertension, type 2 diabetes,
Allergies: PCN, Etodolac, Codeine, ASA
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient received her first Moderna dose on 03/12/21 at 1:24pm in the Right Deltoid, Lot# 036A21A, no reaction after 15 min. No reaction was reported 15 min. after her second dose which was in the opposite arm. See was being watched by her family members that evening, family members did not report anything at that time. Her temperature on 4/16/21 was 97.1


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