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

This is VAERS ID 976166

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Case Details

VAERS ID: 976166 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-07
Onset:2021-01-18
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Senior Living       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: Gabapentin Capsule 100 MG, Give 1 capsule orally one time a day for (NEURALGIA) Losartan Potassium Tablet 50 MG, Give 1 tablet orally one time a day for (HYPERTENSION) HOLD IF SBR<110 OR HR<60 Norvasc Tablet 5 MG (amLODIPine Besylate), Give
Current Illness: NONE
Preexisting Conditions: HEMIPLEGIA AND HEMIPARESIS FOLLOWING NONTRAUMATIC INTRACEREBRAL HEMORRHAGE AFFECTING RIGHT DOMINANT SIDE CONTACT WITH AND (SUSPECTED) EXPOSURE TO OTHER VIRAL COMMUNICABLE DISEASES ACIDOSIS ANEMIA UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION PERSONAL HISTORY OF OTHER MALIGNANT NEOPLASM OF LARGE INTESTINE ACUTE KIDNEY FAILURE, UNSPECIFIED UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE NEURALGIA AND NEURITIS, UNSPECIFIED ESSENTIAL (PRIMARY) HYPERTENSION
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: ASYMPTOMATIC


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