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

This is VAERS ID 1758643

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Case Details

VAERS ID: 1758643 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-08-27
Onset:2021-09-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 054C21A / 3 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: nystatin, Lasix, Toprol LX, Norco, Vitamin D3, mycophenolate, hydroxyzine, Protonix, Aldactone, Synthroid, betamethasone dipropionate
Current Illness: Chronic Lung disease, AS, right sided heart failure, LE edema, On oxygen via NC, mucositis,
Preexisting Conditions: Interstitial lung disease, right-sided heart failure, leg edema, neuralgia, dyslipidemia, hypertension, NASH
Allergies: Lisinopril, Morphine Sulfate, Oxycodone-acetaminophen, Sulfonamide Antibiotics
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient died.


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