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From the 6/4/2021 release of VAERS data:

This is VAERS ID 1006216



Case Details

VAERS ID: 1006216 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-02-02
Onset:2021-02-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: Medications the resident was currently recieving: AmLODIPine Besylate Tablet 5 MG Losartan Potassium Tablet 50 MG Melatonin Tablet 5 MG Povidone-Iodine Solution 10 % Remeron Tablet 15 MG (Mirtazapine) Tamsulosin HCl Capsule 0.4 MG Lactobaci
Current Illness: None
Preexisting Conditions: ESSENTIAL (PRIMARY) HYPERTENSION ATRIOVENTRICULAR BLOCK, COMPLETE NONRHEUMATIC AORTIC (VALVE) STENOSIS WITH INSUFFICIENCY PAROXYSMAL ATRIAL FIBRILLATION HYPOXEMIA BRADYCARDIA, UNSPECIFIED PRESENCE OF UROGENITAL IMPLANTS
Allergies: No known allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Notes of the checks/events with resident: 18:36 2/2/21 Resident had no complaint of pain, swelling, redness or warmth to vaccine site. No signs and symptoms of fever, chills, tiredness or headache. T 97.2 02:50 2/3/2021 Resident received 2nd COVID vaccine. No complaint of pain, swelling, redness or warmth to vaccine site. No signs and symptoms of fever, chills, tiredness or headache. T 98.1 07:15 2/3/2021 Resident was observed not breathing. 911 was contacted along with the doctor. Resident was confirmed having passed away.


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=1006216


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