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

This is VAERS ID 1051050



Case Details

VAERS ID: 1051050 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-01-15
Onset:2021-01-19
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Cardiac failure acute, Cardiogenic shock
SMQs:, Cardiac failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Cardiomyopathy (broad)

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: DEPFIZER INC2021173800

Write-up: Cardiogenic shock; Acute cardiac insufficiency; This is a spontaneous report from a non-contactable physician downloaded from the Agency Regulatory Authority-WEB (Regulatory Authority number DE-PEI-PEI2021002626). A 100 years old female received the first single dose of BNT162B2 (COMIRNATY) on 15Jan2021, for COVID-19 immunization. Medical history and concomitant medications were not reported. On 19Jan2021, four days after vaccination, the patient developed cardiogenic shock and acute cardiac insufficiency, lasting for 5 days. The patient died on an unspecified date in 2021. Cause of death was reported as acute cardiac insufficiency, however both cardiogenic shock and acute cardiac insufficiency were reported with a fatal outcome. Stop date of both events was reported as 23Jan2021 (death date was not clearly specified). It was unknown if an autopsy was done. Relatedness of drug to reaction(s)/event(s) assessed as D. Unclassifiable by Regulatory Authority. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Acute cardiac insufficiency; Cardiogenic shock


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