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

This is VAERS ID 1104932

Case Details

VAERS ID: 1104932 (history)  
Form: Version 2.0  
Sex: Female  
Location: Foreign  
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Death, Dyspnoea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 11
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: Cardiac failure chronic
Preexisting Conditions:
Diagnostic Lab Data: Test Name: COVID-19 Test porsitiv; Result Unstructured Data: Test Result:Positive; Comments: tests in the old people''s home was negative. After the hospitalisation was the COVID-.PCR-Test positive
CDC Split Type: DEPFIZER INC2021266944

Write-up: shortness of breath; PCR test was then made and turned out positive; Death; This is a spontaneous report downloaded from the Regulatory Authority-WEB regulatory authority number DE-PEI-CADR2021017328. A non-contactable consumer reported that a 95-year-old female patient received BNT162b2 (COMIRNATY, solution for injection, batch/lot: unknown), via an intramuscular route of administration on 09Jan2021 at single dose for COVID-19 immunization. Medical history included ongoing cardiac failure chronic. Concomitant medications was not reported. Heart failure / the person complained 10 days after vaccination about shortness of breath and thus directed to the city hospital. The person was from the beginning of December in quarantine since there was a positive case in the home. All PCR tests were negative. In the hospital a PCR test was then made and turned out positive. On 02Feb2021 the person died. The cause of death was unknown. Outcome of death was fatal and outcome of both events was not recovered. Causality from regulatory authority: Inconsistent causal association to immunization No follow-up attempts are needed, follow-up automatically provided by regulatory authority.; Reported Cause(s) of Death: Unknown cause of death

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