Adverse Event Reporting

VAERS ID 914621
Gender Female
Age 89
StateCode IA
Pharmaceutical Company MODERNA
Lot Number 011J02A
Number of vaccinations 1
Vaccinated 2020-12-22
Onset 2020-12-27
Condition Died
  • Fatigue
  • Death
  • Dementia

Current Illness


Preexisting Conditions

Resident in long term care facility for 9+ years Coronary Artery Disease Dementia Hypothyroidism Hypertension

Other Medications

Previous Vaccinations


Laboratory Data


Resident in our long term care facility who received first dose of Moderna COVID-19 Vaccine on 12/22/2020, only documented side effect was mild fatigue after receiving.
She passed away on 12/27/2020 of natural causes per report.
Has previously been in & out of hospice care, resided in nursing home for 9+ years, elderly with dementia.
Due to proximity of vaccination we felt we should report the death, even though it is not believed to be related.