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

This is VAERS ID 1759308

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Case Details

VAERS ID: 1759308 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-04-01
Onset:2021-05-04
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Adult failure to thrive, Asymptomatic COVID-19, COVID-19, Death, Dementia, Dementia Alzheimer's type, Glaucoma, Hyperlipidaemia, Pulmonary hypertension, SARS-CoV-2 test positive, Sepsis, Vaccine breakthrough infection
SMQs:, Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Dementia (narrow), Pulmonary hypertension (narrow), Noninfectious encephalopathy/delirium (broad), Glaucoma (narrow), Lipodystrophy (broad), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-22
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Cardiovascular disease, Renal disease
Allergies:
Diagnostic Lab Data: 05/04/2021 PCR+ COVID-19 test
CDC Split Type:

Write-up: Asymptomatic breakthrough COVID-19 case. Death 5/22/2021. From Records cod = ALZHEIMER''S DEMENTIA, COVID 19, HYPERLIPIDEMIA, PULMONARY HYPERTENSION. Other patient details: pt has dementia, adult failure to thrive . glaucoma, and sepsis. place of death: HOSPITAL-EMERGENCY ROOM/OUTPATIENT; certified by: PRONOUNCING AND CERTIFYING PHYSICIAN; occupation: PLAYGROUND DIRECTOR-BOARD OF ELECTIONS


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