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

This is VAERS ID 1049613

Case Details

VAERS ID: 1049613 (history)  
Form: Version 2.0  
Sex: Female  
Location: Foreign  
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Ex-smoker; Hypertension
Diagnostic Lab Data: Test Date: 20210104; Test Name: PCR Corona test; Test Result: Positive
CDC Split Type: DEPFIZER INC2021017031

Write-up: PCR Corona test positive; This is a spontaneous report based on information received by Pfizer from BIONTECH, license party for BNT162B2, from other healthcare professional from a nursing home. This reporter reported seven similar reports. This is the second of the seven reports. An 86-year-old female patient (resident number 1) of unspecified age and gender received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 31Dec2020 at single dose for COVID-19 immunization. The patient medical history included hypertension and former smoker. Concomitant medications included: kelina, ketoconazole (KETOZOL), acetylsalicylic acid (ASS), pregabalin, folic acid (FOLSAN) and novaminsulfon. The patient experienced PCR Corona test positive on 04Jan2021. Patient was quarantined. The patient displayed clinical signs at rest indicative of severe systemic illness included: Fever, dyspnea, respiratory complaints. The patient was hospitalized, also admitted to Intensive Care Unit. It was also reported from same reporter that the patient had not a positive test for SARS-CoV2. The patient was required supplemental oxygen (including high flow or ECMO) or receive mechanical ventilation in Intensive Care Unit. The patient''s outcome with COVID-19 reported as Death on 17Jan2021. The patient died on 17Jan2021. It was unknown if an autopsy was performed and the reported cause of death was COVID-19. Information on the lot/batch number has been requested. Follow-up (18Feb2021): New information received from the contactable other healthcare professional from a nursing home includes: patient''s age, gender, medical history added, concomitant medications added, serious criteria for event COVID-19 upgraded as death. Event drug ineffective was removed. Follow-up attempts are completed. No further information is expected.; Sender''s Comments: There is not a reasonable possibility that reported "PCR Corona test positive" is related to BNT162B2. Event occurred after 4 days of vaccination, when vaccine was not expected to achieve the effect.,Linked Report(s) : DE-PFIZER INC-2021016519 same reporter, same event, different patient; Reported Cause(s) of Death: PCR Corona test positive

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