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From the 5/7/2021 release of VAERS data (an older release, current is 10/15/2021):

This is VAERS ID 1069118



Case Details

VAERS ID: 1069118 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-25
Onset:2021-03-01
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Dizziness, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   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: albuterol sulfate, Aspir-81, bethanechol chloride, Bevespi, Aerosphere, cholestyramine (with sugar), citalopram, clopidogrel, duloxetine, famotidine, gabapentin, lisinopril, magnesium oxide, megestrol, metoprolol tartrate, mupirocin, nitrog
Current Illness: First covid vaccine received 1/28/2021 without incident. Had been hospitalized prior to vaccination for intractable vomiting.
Preexisting Conditions: history of acute respiratory failure, carotid artery stenosis, chronic back pain, chronic esophagitis, chronic hyperglycemia, chronic obstructive lung disease, chronic sinusitis, coronary arteriosclerosis, depressive disorder, exposure to SARS-CoV-2, history of polyp of colon, hyperlipidemia, hypertensive disorder, hypoxia, nicotine dependence, non-small cell lung cancer, osteoarthritis, peripheral nerve disease, peripheral vascular disease, tremor
Allergies: codeine, Zithromax
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Within 10 minutes following the second vaccination, patient reported dizziness and nausea, had an episode of vomiting but recovered within 30 minutes. It was reported to our clinic that the patient was found deceased on March 1, 2021 at approximately 10 pm. Cause of death is not determined at this time.


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1069118

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