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

This is VAERS ID 972113



Case Details

VAERS ID: 972113 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Epistaxis, Lethargy, Mouth haemorrhage, Pneumonia
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Pantoprzole, Miralax, Potassium, buspirone, Aspirin 81mg, Atenolol, Depakote, Glucosamine-chondroitin, mirabegron ER, Zyprexa, Atorvastatin, Ocuviteeye&MVM
Current Illness: Resident was Dx with pneumonia the day after vaccine.
Preexisting Conditions: ENCEPHALOPATHY, UNSPECIFIED, ACUTE KIDNEY FAILURE, UNSPECIFIED,UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE, UNSTEADINESS ON FEET, UNSPECIFIED HEARING LOSS, UNSPECIFIED EAR, DRY EYE SYNDROME OF BILATERAL LACRIMAL GLANDS, CONSTIPATION, UNSPECIFIED, LONG TERM (CURRENT) USE OF ASPIRIN,MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXED , GENERALIZED ANXIETY DISORDER, AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE,HYPERLIPIDEMIA, UNSPECIFIED, LOCALIZED EDEMA, ESSENTIAL (PRIMARY) HYPERTENSIONGASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS, UNSPECIFIED URINARY INCONTINENCE,
Allergies: NKA
Diagnostic Lab Data: No test performed. Resident''s family did not wish for any tx to be provided. Comfort measures only
CDC Split Type:

Write-up: Resident became lethargic and reports of blood coming from resident''s nose and mouth on the morning of 1/13/21. Resident went out to ER for eval, and came back to facility with dx of pneumonia and recommendations for resident to be placed on hospice. Resident deceased on 1/14/21. Unknown if vaccine related, but with timeline of events I was advised to report this per medical director of facility, as well as Pharmacy who administered the vaccine.


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