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

This is VAERS ID 1064507



Case Details

VAERS ID: 1064507 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-10
Onset:2021-01-13
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM0477 / UNK - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: DEPFIZER INC2021199870

Write-up: Death; This is a spontaneous report from a non-contactable physician downloaded from the Regulatory Authority-WEB with regulatory authority report number DE-PEI-PEI2021002773. A 76-year-old male patient received bnt162b2 (COMIRNATY, lot/batch number: EM0477), intramuscularly on 10Jan2021 at single dose for covid-19 immunisation. The patient''s medical history and concomitant medications were not reported. After vaccination, the patient died on 13Jan2021, lasting for unknown. An autopsy was not performed. Event Assessment: Attending Physician / C. Inconsistent causal association. No follow up attempts are possible. No further information is expected.; Reported Cause(s) of Death: Death


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