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

This is VAERS ID 1104926



Case Details

VAERS ID: 1104926 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-01-12
Onset:2021-01-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Apathy, Death
SMQs:, Dementia (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Dementia; Heart disease, unspecified
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: DEPFIZER INC2021266975

Write-up: Unknown cause of death; mouth wide open, apathy; This is a spontaneous report from a non-contactable consumer or other non-HCP downloaded from the Agency Regulatory Authority-WEB, regulatory authority number: DE-PEI-CADR2021014885, DE-CADRPEI-2021014885, DE-PEI-2021005337. A 92-year-old female patient received BNT162B2 (COMIRNATY, Solution for injection, LOT/Batch number and expiration date unknown) via an unspecified route of administration on 12Jan2021 at single dose for COVID-19 immunisation. Medical history included ongoing dementia and ongoing heart disease. Concomitant medications were not reported. The patient''s weight was not reported, and height was not reported. On 14Jan2021, the patient experienced mouth wide open, apathy. On 23Jan2021, the patient experienced unknown cause of death. It was unknown if an autopsy was performed. Outcome of mouth wide open, apathy was unknown, of unknown cause of death was fatal. Sender Comment: dementia, medical therapy of heart. Reported causality assessment for both events: source of assessment was Regulatory Authority, result of assessment was inconsistent causal association to immunization. No follow-up attempts are possible. No further information is expected. Information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Unknown cause of death


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