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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 1273804

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Case Details

VAERS ID: 1273804 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Unknown  
Location: Michigan  
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Gastrointestinal haemorrhage, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Ischaemic colitis (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-29
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cardizem Norco Neurontin banophen Plavix
Current Illness: None known
Preexisting Conditions: HTN S/P Heart Transplant Hyperparathyroidism Reflux End stage renal disease
Allergies: Aspirin Atrorvastatin Crestor Haldol Haloperidol Lipitor Lisinopril Oxycodone Aldactone Hydralazine
Diagnostic Lab Data:
CDC Split Type:

Write-up: GI Hemorrhage Covid + Respiratory Failure

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