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

This is VAERS ID 1377208

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Case Details

VAERS ID: 1377208 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-04-10
Onset:2021-04-13
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-06-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Influenza, Pneumonia, SARS-CoV-2 test
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-26
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: VIMOVO; ACEMIN [ACECLOFENAC]; SEDACORON; ELIQUIS; MEXALEN; CONCOR; CAL-D-VITA; OLEOVIT D3
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Atrial fibrillation (Heart failure and atrial fibrillation(but condition was stable according to internist)); Cardiac insufficiency (Heart failure and atrial fibrillation(but condition was stable according to internist)); COVID-19 PCR test negative
Allergies:
Diagnostic Lab Data: Test Name: PCR test; Test Result: Negative ; Result Unstructured Data: Negative
CDC Split Type: ATMODERNATX, INC.MOD20211

Write-up: Bilateral bacterial pneumonia; Flu symptoms; This regulatory authority case was reported by a consumer and describes the occurrence of PNEUMONIA (Bilateral bacterial pneumonia) in a 73-year-old female patient who received mRNA-1273 (COVID 19 Vaccine Moderna) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included Cardiac insufficiency (Heart failure and atrial fibrillation(but condition was stable according to internist)), Atrial fibrillation (Heart failure and atrial fibrillation(but condition was stable according to internist)) and COVID-19 PCR test negative. Concomitant products included ACECLOFENAC (ACEMIN [ACECLOFENAC]) for COVID-19 vaccination, ESOMEPRAZOLE MAGNESIUM, NAPROXEN (VIMOVO), AMIODARONE HYDROCHLORIDE (SEDACORON), APIXABAN (ELIQUIS), PARACETAMOL (MEXALEN), BISOPROLOL FUMARATE (CONCOR), CALCIUM CARBONATE, COLECALCIFEROL (CAL-D-VITA) and COLECALCIFEROL (OLEOVIT D3) for an unknown indication. On 10-Apr-2021 at 2:00 PM, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 13-Apr-2021, the patient experienced PNEUMONIA (Bilateral bacterial pneumonia) (seriousness criterion death) and INFLUENZA (Flu symptoms). On 26-Apr-2021, INFLUENZA (Flu symptoms) outcome was unknown. The patient died on 26-Apr-2021. The reported cause of death was Pneumonia and Decompensation cardiac. An autopsy was not performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, SARS-CoV-2 test: negative (Negative) Negative. Treatment medications were not reported. Very limited information regarding this patient''s death has been provided at this time. Most recent FOLLOW-UP information incorporated above includes: On 28-May-2021: Translation received on 02-JUN-2021 and added lab data.; Sender''s Comments: Very limited information regarding this patient''s death has been provided at this time.; Reported Cause(s) of Death: Pneumonia; Decompensation cardiac


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