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

This is VAERS ID 1048252



Case Details

VAERS ID: 1048252 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Foreign  
Vaccinated:2020-12-29
Onset:2020-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNKNOWN / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Multi-organ disorder, SARS-CoV-2 test
SMQs:, Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-02
   Days after onset: 4
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:
Allergies:
Diagnostic Lab Data: Test Date: 20201229; Test Name: SARS-CoV-2 PCR test; Test Result: Positive ; Comments: qualitative
CDC Split Type: DEPFIZER INC2021164676

Write-up: Multi-organ disorder; SARS-CoV-2 PCR test: positive; This is a spontaneous report from a non-contactable physician downloaded from the Medicines Agency (MA) Regulatory authority- WEB [DE-PEI-PEI2021002546] received via Regulatory Authority. An 87-year-old male patient received first dose of bnt162b2 (COMIRNATY), via an unspecified route of administration on 29Dec2020 at single dose for prophylactic vaccination. The patient''s medical history and concomitant medications were not reported. The patient underwent lab tests and procedures which included SARS-CoV-2 PCR test: positive, qualitative on 29Dec2020 4 h after vaccination. 5 days after vaccination the patient developed multi-organ disorder, lasting for unknown. Outcome of event SARS-CoV-2 PCR test: positive was unknown. The patient was dead on 02Jan2021. Reported cause of death was multi-organ disorder. It was unknown if an autopsy was performed. Reporter''s comments: 4 h after vaccination: SARS-CoV-2 PCR positive. Sender Comment: Multi-morbid full-time nursing home resident died on 02Jan2021 of her many illnesses. No symptoms developed after vaccination. Causality assessment by RA for Comirnaty / Multi-organ disorder: D. Unclassifiable. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reporter''s Comments: 4 h after vaccination: SARS-CoV-2 PCR positive; Reported Cause(s) of Death: Multi-organ disorder


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