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

This is VAERS ID 1105012



Case Details

VAERS ID: 1105012 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-14
Onset:2021-01-30
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: BISOPROLOL FUMARATE; FULTIUM-D3; RIVAROXABAN; SIMVASTATIN
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: GBPFIZER INC2021245858

Write-up: Death; This is a spontaneous report from a contactable pharmacist. This is a report received from the Regulatory Agency. Regulatory authority report number GB-MHRA-EYC 00242663, Safety Report Unique Identifier GB-MHRA-ADR 24875322. An 89-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), intramuscular on 14Jan2021 at single dose for COVID-19 immunization. The patient medical history was not reported. Concomitant medication included bisoprolol fumarate, colecalciferol (FULTIUM-D3), rivaroxaban and simvastatin. The patient''s death occurred on 30Jan2021, unknown cause of death. It was not reported if an autopsy was performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: unknown cause of death


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