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From the 10/8/2021 release of VAERS data:

This is VAERS ID 972890



Case Details

VAERS ID: 972890 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: New York  
Vaccinated:2020-12-29
Onset:2021-01-10
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Communication disorder, Confusional state, Death, Feeding disorder, Oxygen saturation decreased, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: COVID-19 positive on November 19, 2020 and didn''t test negative until December 26, 2020
Preexisting Conditions: Macular Degeneration
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: On the evening of 10JAN2021, patient experienced a low grade fever, decreased oxygen saturation of 38%, heart rate of 124, confusion. Patient received oxygen via face mask, morphine and ativan. By 11JAN2021, patient was no longer verbal, able to eat or communicate and was kept on comfort measure only. On the morning of 17JAN2021, the patient passed away.


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