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

This is VAERS ID 1745752

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Case Details

VAERS ID: 1745752 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-09-16
Onset:2021-09-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 050EZ1A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Computerised tomogram, Computerised tomogram thorax, Death, Depressed level of consciousness, Dysphagia, General physical health deterioration, Magnetic resonance imaging head normal, Monoplegia, Pyrexia, Respiratory distress, Speech disorder
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-25
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: amlodipine /pantoprazole /vit d /vit b 12
Current Illness: none
Preexisting Conditions: hypertension
Allergies: none known
Diagnostic Lab Data: magnetic scans of brain x 2 / cat scans x 1 / cat scan of chest /
CDC Split Type:

Write-up: fever and weakness day after vaccine with increasing weakness at home /admitted to hospital 4 days later with weakness /progressive decline with weakness and paralysis of left arm / stroke suspected but could not be confirmed on 2 magnetic resonance scans /inability to speak and then swallow / treated for possible aspiration pneumonia /progressed to being obtunded and respiratory distress / died 9/25/21


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