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

This is VAERS ID 1461692

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Case Details

VAERS ID: 1461692 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-06-17
Onset:2021-06-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-07-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EWO183 / 2 RA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain upper, Asthenia, Cardiac arrest, Death, Fatigue, Resuscitation, Secretion discharge, Somnolence, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-19
   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: none
Current Illness: COPD
Preexisting Conditions: COPD, severe Arthritis, Hypertension, Chronic kidney disease stage 111
Allergies: none known
Diagnostic Lab Data: 911 came at 2 AM on 06-19-2021. Asked if this could be vaccine related and was told it could be. Even with the stomach pain and mucus, all vital signs were normal. Since she just had her shot & was not yet fully protected, we all thought it best to wait til 8 AM & call Dispatch & not risk going to emergency risking Covid.
CDC Split Type:

Write-up: Fine in Am. Started complaining of stomach pain in afternoon. Had dinner around 6 pm & threw up part of it along with clear mucus and all the water she drank. After that it was all clear mucus off & on through the night. Has had this episode before but only lasting a few minutes never this long! Tried to give water but kept coming back up. Meanwhile pain in stomach (pelvic area) was getting worse. Called 911 at 2 AM (see line 19). Sometime after 911 left, the clear mucus started coming at a faster rate. Had bowel movement around 6 AM but said no relief in stomach pain. Called at 8Am. Could not come til between 12-1 PM. Seemed weak and very tired so let sleep. Around 10-10:30 AM could not wake her up. Called 911 again. This time it was cardiac arrest and they could not revive her.


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