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From the 6/11/2011 release of VAERS data (an older release, current is 6/11/2021):

This is VAERS ID 376969



Case Details

VAERS ID: 376969 (history)  
Form: Version .0  
Age: 75.0  
Sex: Female  
Location: Unknown  
Vaccinated:2010-01-06
Onset:2010-01-09
   Days after vaccination:3
Submitted: 2010-01-14
   Days after onset:5
Entered: 2010-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) SANOFI) / SANOFI PASTEUR UP035BA / 0 RA / IM

Administered by: Private       Purchased by: Public
Symptoms: Anaemia, Cardiomyopathy, Coagulopathy, Condition aggravated, Death, Drug interaction, General physical health deterioration, Injection site haematoma, International normalised ratio increased, Lymphoplasmacytoid lymphoma/immunocytoma, Muscle spasms, Myelodysplastic syndrome, Non-Hodgkin's lymphoma, Packed red blood cell transfusion, Pain in extremity, Transfusion, Vaccination complication
SMQs:, Liver-related coagulation and bleeding disturbances (narrow), Haematopoietic cytopenias affecting more than one type of blood cell (broad), Haematopoietic erythropenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Blood premalignant disorders (narrow), Dystonia (broad), Cardiomyopathy (narrow), Malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2010-01-11
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: COUMADIN
Current Illness: NonHodgkins Lymphoma
Preexisting Conditions: lymphoma; chronic DVT
Allergies:
Diagnostic Lab Data: Increased INR
CDC Split Type:

Write-up: Suspect H1N1 caused interaction with COUMADIN/coagulation.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20110611&IDNUMBER=376969


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