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From the 5/7/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 1068901



Case Details

VAERS ID: 1068901 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-01-30
Onset:2021-02-21
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Aortic dissection, Aortitis, Arteritis coronary, Cardioversion, Chest pain, Computerised tomogram, Computerised tomogram normal, Death, Echocardiogram, Electrocardiogram, Electrocardiogram normal, Fatigue, Inflammation, Laboratory test, Pain in jaw, Pulse absent, Red blood cell sedimentation rate normal, Respiratory arrest, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Vasculitis (narrow), Osteonecrosis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   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: Prednisone BP medication
Current Illness: COVID prior to vaccination - still having symptoms SOB, Tired, foggy head -thinking
Preexisting Conditions: GCA Arthritis
Allergies:
Diagnostic Lab Data: 2/17-2/19 hospital admit Medical Center Labs, CT, Echo 2/21 EMTs conducted EKGs
CDC Split Type:

Write-up: ER admit for CP and Jaw pain, exhaustion, Aortic arteritis normal SED rate found on CT scan hospital admit IV medications required Solumedrol and Actemra questionable how much medications received d/t IV''s not working. Released from care on 2/19 with prednisone . Symptoms still present off and on. 2/21 922pm CP Jaw Pain severe EMT''s called EKG done reported no heart attack, pain better, EMTs left. 10/15 severe Pain collapsed with no pulse and no breathing, EMTs returned unable to obtain a shock-able rhythm time of death pronounced. reason for death on certificate Aortitis - hospitalist thinks aortic dissection d/t severe inflammation


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1068901

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