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From the 4/30/2021 release of VAERS data:

This is VAERS ID 924186



Case Details

VAERS ID: 924186 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Michigan  
Vaccinated:2020-12-30
Onset:2021-01-03
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

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: aldactone, lasix, aspirin, tylenol, potassium, spiriva
Current Illness: Covid positive previous with no s/s poor appetite Chronic wound right leg
Preexisting Conditions: alzheimers dementia, COPD , DM- type 2
Allergies: Codeine, Penicillin, Sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident expired 1/3/21


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=924186


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