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

This is VAERS ID 1048259



Case Details

VAERS ID: 1048259 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-01
Onset:2021-01-10
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM0477 / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Cough, Diet refusal, General physical health deterioration, Restlessness, SARS-CoV-2 test, SARS-CoV-2 test positive, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Akathisia (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 13
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: Basal cell carcinoma; Coxarthrosis; Dementia Alzheimer''s type; Prostatic adenoma; Squamous cell carcinoma
Allergies:
Diagnostic Lab Data: Test Date: 20210111; Test Name: COVID-19 PCR test; Result Unstructured Data: Test Result:positiv/positive NA; Test Date: 20210110; Test Name: COVID-19 rapid POC test; Result Unstructured Data: Test Result:positiv/positive NA
CDC Split Type: DEPFIZER INC2021164542

Write-up: Sudden death; Refusal to eat; Deterioration in general condition; Restlessness; cough; COVID-19 PCR test/COVID-19 rapid POC test : positiv/positive NA; This is a spontaneous report from a non-contactable physician downloaded from the Medicines Agency (MA) Regulatory Authority-WEB DE-PEI-PEI2021002569. An 83-years-old male patient received first dose of bnt162b2 (COMIRNATY, Lot# no.: EM0477), via an unspecified route of administration on 01Jan2021 at single dose for covid-19 immunisation. Medical history included Dementia Alzheimer''s type, Coxarthrosis, Basal cell carcinoma, Squamous cell carcinoma, Prostatic adenoma. The patient''s concomitant medications were not reported. The patient experienced refusal to eat on 15Jan2021, cough on 12Jan2021, deterioration in general condition on 15Jan2021, restlessness on 12Jan2021. Clinical course reported as: 11 day(s) after vaccination the patient developed Cough and Restlessness and General physical health deterioration and Diet refusal, lasting for 12 day(s). The patient underwent lab tests and procedures which included COVID-19 PCR test: positiv/positive NA on 11Jan2021, COVID-19 rapid POC test: positiv/positive NA on 10Jan2021. The patient died on 23Jan2021. It was not reported if an autopsy was performed. Events refusal to eat, cough, deterioration in general condition, restlessness were reported as serious with seriousness criterion death. Cause of death was reported as sudden death. No follow-up attempts are possible, batch number already obtained.; Reported Cause(s) of Death: Restlessness; General physical health deterioration; cough; Refusal to eat; Sudden death


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