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From the 10/15/2021 release of VAERS data:

This is VAERS ID 958069



Case Details

VAERS ID: 958069 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-14
Onset:2021-01-19
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cough, Dyspnoea, Feeling abnormal
SMQs:, Anaphylactic reaction (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cartia XT 120mg daily, Zaditor 0.025% 1 drop into eye twice a day, Folic Acid 1mg daily, Metoprolol Succinate ER 100mg twice a day, Lasix 40mg daily, Erythromycin 2% to area twice a day, Hydroxychloroquine Sulfate 200mg 2 tabs daily, Ferrou
Current Illness: None
Preexisting Conditions: Rheumatoid arthritis, osteoarthritis, lumbar spinal stenosis, diabetes, bradycardia with pacemaker
Allergies: Codeine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Started with cough, mild shortness of breath and feeling terrible in evening of 1/19.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=958069

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