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From the 5/14/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1169683

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Case Details

VAERS ID: 1169683 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-02-25
Onset:2021-02-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Chills, Death, Fatigue, Nausea, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lantus insulin, levothyroxine, losartan, Protonix, potassium, sertraline, spironolactone, vitamin D3, amiodarone, aspirin, atorvastatin, clonidine, plavix, donepazil, iron, and labetolol.
Current Illness: Cerebrovascular disease, vascular dementia with hallucinations, atherosclerotic cardiovascular disease, hypertension, atrial fibrillation, pacemaker placement, Watchman placement (Aug 2020), congestive heart failure, pulmonary hypertension, peripheral vascular disease, diabetes mellitus type II, reflux, anemia, hypothyroidism, osteoporosis, history of compression fracture, anxiety, depression, and history of nicotine use. Hospitalized in November 2020 for fatigue and not eating - was reportedly losing blood but unknown from where. She was given a blood transfusion and fluids. It was a suspected GI bleed but family declined a hematology workup.
Preexisting Conditions: Cerebrovascular disease, vascular dementia with hallucinations, atherosclerotic cardiovascular disease, hypertension, atrial fibrillation, pacemaker placement, Watchman placement (Aug 2020), congestive heart failure, pulmonary hypertension, peripheral vascular disease, diabetes mellitus type II, reflux, anemia, hypothyroidism, osteoporosis, history of compression fracture, anxiety, depression, and history of nicotine use. Hospitalized in November 2020 for fatigue and not eating - was reportedly losing blood but unknown from where. She was given a blood transfusion and fluids. It was a suspected GI bleed but family declined a hematology workup.
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Within 5-10 hours of the second dose: nausea, vomiting, chills, fever, fatigue. Chills, fatigue and nausea continued for 10 days until death


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