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

This is VAERS ID 1067539



Case Details

VAERS ID: 1067539 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-22
Onset:2021-02-03
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1491 / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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 INC2021213046

Write-up: the fatal outcome; This is a spontaneous report from a non-contactable physician downloaded from the regulatory authority DE-PEI-PEI2021002863. A 92-year-old male patient received BNT162B2 (COMIRNATY, batch/lot number EL1491) on 22Jan2021 (at the age of 92-year-old), at single dose, for COVID-19 immunization. The patient medical history and concomitant medications were not reported. The patient experienced "the fatal outcome" on 03Feb2021. On 03Feb2021 after vaccination the patient developed death. The patient was dead. The outcome of the event was fatal. It was unknown whether autopsy was performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: the fatal outcome


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