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

This is VAERS ID 1048255



Case Details

VAERS ID: 1048255 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-02-03
Onset:2021-02-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / OT

Administered by: Other       Purchased by: ?
Symptoms: General physical health deterioration
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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:
CDC Split Type: DEPFIZER INC2021164500

Write-up: General physical health deterioration; This is a spontaneous report from a non-contactable physician downloaded from the Medicines Agency (MA) Regulatory Authority-WEB, Regulatory Authority number DE-PEI-PEI2021002561. A 98-year-old male patient received the second dose bnt162b2 (COMIRNATY), intramuscular on 03Feb2021 at SINGLE DOSE for covid-19 immunisation. The patient''s medical history and concomitant medications were not reported. The patient previously received the first dose bnt162b2 (COMIRNATY) in Jan2021 for covid-19 immunization, and had been tolerated. On 05Feb2021 after vaccination the patient developed general physical health deterioration, lasting for 5 days. No treatment, no hospitalization. The patient died in Feb2021. It was not reported if an autopsy was performed. The outcome of event general physical health deterioration was fatal. Event Assessment: For both events / RA / D. Unclassifiable. No follow-up attempts possible, batch/lot number cannot be obtained.; Reported Cause(s) of Death: General physical health deterioration


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