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

This is VAERS ID 1068295



Case Details

VAERS ID: 1068295 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Oklahoma  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Illness, Malaise, SARS-CoV-2 test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Lupus syndrome
Allergies:
Diagnostic Lab Data: Test Name: COVID-19; Test Result: Negative ; Comments: tested negative 2 times over the following 10 day while deteriorating.; Test Name: COVID-19; Test Result: Negative ; Comments: tested negative 2 times over the following 10 day while deteriorating.; Test Name: COVID-19; Test Result: Positive ; Comments: Was admitted and tested positive and put on ventilator
CDC Split Type: USPFIZER INC2021201566

Write-up: Was admitted and tested positive and put on ventilator; She felt slightly ill the day of vaccine; 2 days later patient become ill; tested negative 2 times over the following 10 day while deteriorating; Patient died 10 days later; This is a spontaneous report from a contactable consumer via Pfizer Sales Representative. This consumer (daughter) was reported for a female patient (mother). A 76-year-old female patient received first dose of bnt162b2 (Pfizer), via an unspecified route of administration on an unspecified date at single dose for covid-19 immunization. Medical history included lupus from an unknown date and unknown if ongoing. The patient''s concomitant medications were not reported. The patient with lupus received 1st dose of vaccine. She felt slightly ill the day of vaccine. 2 days later patient become ill, tested negative 2 times over the following 10 day while deteriorating. Was admitted and tested positive and put on ventilator. Patient died 10 days later. Daughter thought she had COVID before vaccination. Event took place after use of product. The patient underwent lab tests and procedures which included COVID-19: negative (tested negative 2 times over the following 10 day while deteriorating), COVID-19: positive (Was admitted and tested positive and put on ventilator) all on an unspecified date. The patient died on an unspecified date. It was not reported if an autopsy was performed. The outcome of other events was unknown. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Patient died 10 days later


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