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

This is VAERS ID 1055875



Case Details

VAERS ID: 1055875 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-01-12
Onset:2021-01-25
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ6795 / 1 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: Dyspnoea, Malaise
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 0
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: Arteriopathic disease; Cardiac failure; Diabetes; Diabetic nephropathy; Diabetic neuropathy; General physical health deterioration (for several months before the vaccination)
Allergies:
Diagnostic Lab Data:
CDC Split Type: FRPFIZER INC2021180550

Write-up: Respiration labored; Feeling sick; This is a spontaneous report from a contactable physician downloaded from the WEB FR-AFSSAPS-GR20210284 This is a report received from the Regulatory Authority. A 90-year-old (also reported as 93 years old, pending clarification) female patient was received first dose of bnt162b2 (COMIRNATY, lot number: EJ6795) Intramuscular at left arm on 12Jan2021 at single dose for COVID-19 vaccination. Medical history included diabetes with multiple complications: Nephropathy (diabetic nephropathy), Neuropathy (diabetic Neuropathy), Arteriopathy (Arteriopathic disease), Heart failure (Cardiac failure), all from unknown date and unknown if ongoing. Long-term treatment was not specified. The patient has had a deterioration in her general condition for several months before the vaccination. Concomitant medication was not reported. The deterioration in the patient''s general condition continues in the weeks following vaccination. The patient has no other side effects from the vaccine. On25Jan2021, the patient is unwell and has difficulty breathing. differential diagnosis was very poor general condition. Patient was died on 25Jan2021 for respiration labored and feeling sick. Cause of death was also reported as reduced general condition. The autopsy was not done. No follow-up attempts possible. No further information expected. Information on lot and batch numbers already obtained. ; Reported Cause(s) of Death: Reduced general condition; Respiration labored; Feeling sick


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