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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1048403



Case Details

VAERS ID: 1048403 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
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: GBPFIZER INC2021170379

Write-up: Passed away; This is a spontaneous report from a contactable consumer (patient''s son). A male patient of unspecified age received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) on an unspecified date, at single dose, for COVID-19 immunisation. Medical history and concomitant medications were not reported. The patient passed away 19 days after receiving the vaccine, on an unknown date. No further information about case of death was provided. It was unknown if an autopsy was done. Information on the lot/batch number has been requested.; Reported Cause(s) of Death: passed away


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