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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1075435

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Case Details

VAERS ID: 1075435 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-15
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1491 / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 29
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID-19
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210125; Test Name: COVID-19 PCR test; Test Result: Positive.
CDC Split Type: ATPFIZER INC2021221791

Write-up: COVID-19 respiratory infection; This is a spontaneous report from a contactable physician downloaded from the Regulatory Authority -WEB AT-BASGAGES-2021-04881. A 91 years old male patient received first dose of bnt162b2 (COMIRNATY, Lot Number EL1491 and Expiration Date unknown) via an unspecified route of administration on 15Jan2021 at single dose for COVID-19 immunisation. The patient''s medical history COVID-19 from unknown date (continuing). The concomitant medications were not reported. In Jan2021 the patient experienced COVID-19 and died on 30Jan2021 from COVID-19 respiratory infection. Lab test included positive COVID-19 PCR test on 25Jan2021. There is no autopsy was done. The outcome of event was fatal. No follow-up attempts are possible. No further information is expected. ; Reported Cause(s) of Death: COVID-19 respiratory infection


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