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From the 1/7/2022 release of VAERS data:

This is VAERS ID 977320

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Case Details

VAERS ID: 977320 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-25
Onset:2021-01-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Dyspnoea, Intensive care, Life support, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: acute pancreatitis, gerd, ibs, OA, rheumatoid arthritis, HTN, H/o falls, osteoporosis, pre-diabetes, hyperlipidemia, diverticulosis, interstitial lung disease, permatomyoitis
Preexisting Conditions: acute pancreatitis, gerd, ibs, OA, rheumatoid arthritis, HTN, H/o falls, osteoporosis, pre-diabetes, hyperlipidemia, diverticulosis, interstitial lung disease, permatomyoitis
Allergies: azathioprine (Imuran)
Diagnostic Lab Data:
CDC Split Type:

Write-up: about 20+ hours after vaccination resident was having hard time breathing, 911 was called. Resident coded multiple times at the facility after CPR she was taken to ICU. She coded again and was placed on life support. Due to her choice to not be on life support she passed on 11/26/2021.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=977320


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