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From the 1/14/2022 release of VAERS data:

This is VAERS ID 963269

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Case Details

VAERS ID: 963269 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-04
Onset:2021-01-18
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Work       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Lisinopril, Januvia, Fosamax, Trazodone, Metoprolol, Colace Simvastatin, Levoxyl, Lantus, Zocor
Current Illness:
Preexisting Conditions: Type 2 Diabetes, HTN, DJD, Blindness bilateral, Glaucoma, Dyslipidemia, Diverticulosis, Osteoporosis, Memory loss, Chronic renal failure, CAD
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 01/18/2021


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