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

This is VAERS ID 997677



Case Details

VAERS ID: 997677 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-02-01
Onset:2021-02-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood pressure increased, Cerebrovascular accident, Coma scale abnormal, Death, General physical health deterioration, Heart rate increased, Loss of consciousness, Posturing, Pulmonary embolism
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Dystonia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan, dilTIAZem, Omeprazole, Ipratropium-Albuterol Solution, Perforomist Nebulization Solution, Furosemide, Budesonide Suspension, Levothyroxine , PARoxetine, Melatonin, Ibuprofen, Aspirin, Cholecalciferol, Docusate Sodium Capsule, ARIP
Current Illness:
Preexisting Conditions: PULMONARY FIBROSIS, CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, HYPOTHYROIDISM, HYPERTENSION, IRON DEFICIENCY ANEMIAS
Allergies: Amlodipine, Ciprofloxacin, Citalopram, Codeine, Penicillin, traMADol, Spiriva Respimat, Sulfa Antibiotics
Diagnostic Lab Data: Family declined treatment or diagnostic testing. Dr signed comfort orders, verbalized probable PE or stroke
CDC Split Type:

Write-up: Rapid decline in health status, Elevated BP&P, posturing, loss of consciousness, Glasgow coma Scale 4 starting 2/1/2021, Deceased 2/3/21


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=997677

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