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

This is VAERS ID 1753893

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Case Details

VAERS ID: 1753893 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Female  
Location: Alabama  
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002F21A / 1 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Anticoagulant therapy, Computerised tomogram thorax abnormal, Dyspnoea, Endotracheal intubation, Mechanical ventilation, Multiple organ dysfunction syndrome, Positive airway pressure therapy, Pulmonary embolism, Vena cava filter insertion
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-09-29
   Days after onset: 39
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 24 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Humira Prednisone
Current Illness:
Preexisting Conditions: Diabetic Rheumatoid Arthritis
Diagnostic Lab Data:
CDC Split Type:

Write-up: 10 days after receiving the first dose of Moderna, patient presented at the ER with difficulty breathing. CT revealed bi-lateral pulmonary embolisms. A few days on anti-coagulants and was released. She returned a couple days later with worsening breathing. Patient received bi-pap oxygen then underwent procedure to place filter to prevent blood clots from traveling. Patient was intubated and placed on mechanical ventilation and diagnosed with multiple system organ failure. Patient succumbed to the vaccine injury September 29, 2021.

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