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From the 10/8/2021 release of VAERS data:

This is VAERS ID 413836

Case Details

VAERS ID: 413836 (history)  
Form: Version 1.0  
Age: 95.0  
Sex: Female  
Location: Minnesota  
   Days after vaccination:49
Submitted: 2011-01-02
   Days after onset:13
Entered: 2011-01-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Other
Symptoms: Abdominal pain, Decreased appetite, Full blood count normal, Haemoglobin decreased, International normalised ratio decreased, Melaena, Nausea, Platelet count decreased, White blood cell count decreased
SMQs:, Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-01-07
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril; Aspirin; Omeprazole; Diltiazem
Current Illness: None
Preexisting Conditions: Hypertension; Chronic kidney disease; Neurogenic bladder; Allergies: codeine, sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: May of 2010, CBC plt were normal. Dec of 2010, WBC count of 2.5 - hemoglobin = 7.0 - plt = 14 - no schistocystes or RBC fragments to suggest consumptive coagulopathy, no teardrop cells, plts appear nl, INR = 1.29. Patient complaining of melanic stools, abdominal pain, nauseam decreased appetite, for since December 20, 2010.

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