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

This is VAERS ID 418081

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Case Details

VAERS ID: 418081 (history)  
Form: Version 1.0  
Age: 50.0  
Sex: Female  
Location: Unknown  
   Days after vaccination:0
Submitted: 2011-03-04
   Days after onset:154
Entered: 2011-03-07
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Other
Symptoms: Death, Haematoma
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2010-10-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: COUMADIN
Current Illness:
Preexisting Conditions: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type: WAES1102USA03152

Write-up: Information has been received from a doctor of pharmacy concerning a female patient in her 50''s, who in October 2010, was vaccinated with a 0.65 ml dose of ZOSTAVAX (Merck) (Lot # not reported). Concomitant therapy included COUMADIN. The pharmacist reported that the patient received a shot of the ZOSTAVAX (Merck) and then was rushed to the hospital with a hematoma. After being admitted to the hospital the patient passed away, in October 2010, "a week after her shot". The pharmacist was not sure if it was due to the ZOSTAVAX (Merck) or not, and she was also not sure of the length of time between the patient getting the ZOSTAVAX (Merck) and being to the hospital. The pharmacist considered that the hematoma and that the patient "passed away" to be life threatening. Additional information has been requested.

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