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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1457205

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Case Details

VAERS ID: 1457205 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-05-04
Onset:2021-05-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007C21A / 2 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-05
   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: Tramadol, Metoclopramide hydrochloride, Clonidine, Famotidine, Lisinopril, Clonazepam, Amlodipine besylate, Solifenacin, Hydrocodone bitartrate and acetaminophen,
Current Illness:
Preexisting Conditions: Hypertension, hyperlipidemia, & diabetes mellitus
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Reportedly "didn''t feel well" after vaccine but didnt want to seek medical treatment.


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