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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1045014



Case Details

VAERS ID: 1045014 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-14
Onset:2021-01-16
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM0477 / 1 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: Death, SARS-CoV-2 test
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Anticoagulant therapy; Bronchial superinfection; COPD (Severe); Fall (Repeated); Heart failure (under diuretic therapy); Major neurocognitive disorder (of vascular origin); Prostate cancer (with bone metastases); Respiratory failure (Many episodes of); Steroid dependence (Cortico-dependence)
Allergies:
Diagnostic Lab Data: Test Name: PCR test; Result Unstructured Data: Test Result:unknown results
CDC Split Type: FRPFIZER INC2021159141

Write-up: Death; This is a spontaneous report from a contactable physician downloaded from the Medicines Agency (MA) Regulatory authority-WEB, Regulatory authority report number FR-AFSSAPS-CN20210263. A 92-year-old male patient received the first dose of BNT162B2 (COMIRNATY, lot number: EM0477), via intramuscular at left arm on 14Jan2021 at 0.3 mL, single for COVID-19 vaccination. The patient''s medical history included severe chronic obstructive pulmonary disease (COPD), bronchial superinfection, many episodes of respiratory failure, cortico-dependence, heart failure under diuretic therapy, prostate cancer with bone metastases, major neurocognitive disorders of vascular origin, repeated falls and anticoagulant therapy. The patient had no history of COVID-19. Patient had PCR test history with unknown results. COVID-19 risk factors included heart and respiratory failure. Allergic history was unknown. Concomitant medications were not reported. Death was observed on 16Jan2021, without signs of poor tolerance since vaccination. Patient was found dead in bed in the morning. The patient died on 16Jan2021. It was not reported if an autopsy was performed. No follow-up attempts possible. No further information expected.; Reported Cause(s) of Death: Death


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