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

This is VAERS ID 919537

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Case Details

VAERS ID: 919537 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-03
Onset:2021-01-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Pulse absent
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   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: Robitussin Cough+Chest Cong DM Liquid 5-100 MG/5ML (Dextromethorphan-guaiFENesin) Tylenol Extra Strength Tablet (Acetaminophen) amLODIPine Besylate Tablet 5 MG Morphine Solu Tab 2.5MG Capsaicin Cream 0.025 % Leflunomide Tablet 10 MG Levothy
Current Illness: Resident had suspected vasovagal episode with drop in O2 saturation.
Preexisting Conditions: ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE RHEUMATOID ARTHRITIS, UNSPECIFIED ANEMIA, UNSPECIFIED HYPOTHYROIDISM, UNSPECIFIED CACHEXIA ESSENTIAL (PRIMARY) HYPERTENSION DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE AGE-RELATED PHYSICAL DEBILITY OTHER CHRONIC PAIN DILATED CARDIOMYOPATHY ERYTHEMATOUS CONDITION, UNSPECIFIED UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE PRIMARY GENERALIZED (OSTEO)ARTHRITIS OTHER SPONDYLOSIS WITH RADICULOPATHY, LUMBAR REGION HYPERKALEMIA OTHER INTERVERTEBRAL DISC DEGENERATION, LUMBAR REGION AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE CERVICALGIA OTHER BIOMECHANICAL LESIONS OF LUMBAR REGION ??? BILATERAL PRIMARY OSTEOARTHRITIS OF KNEE LOCALIZED EDEMA HYPO-OSMOLALITY AND HYPONATREMIA OTHER SPECIFIED DISORDERS OF BONE DENSITY AND STRUCTURE, UNSPECIFIED SITE HISTORY OF FALLING WEAKNESS
Allergies: Celebrex and Tramadol
Diagnostic Lab Data: N/A.
CDC Split Type:

Write-up: Resident exhibited no adverse events during 30 minute monitoring following vaccine administration. Resident found without pulse at 1900.


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