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

This is VAERS ID 1105793



Case Details

VAERS ID: 1105793 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-03-04
Onset:2021-03-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER1741 / 2 - / -

Administered by: Other       Purchased by: ?
Symptoms: Death, SARS-CoV-2 test
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   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: BUNOV; MEMANTINE; SERTRALINE
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Dementia (significant dementia. Living in a dementia care home)
Allergies:
Diagnostic Lab Data: Test Name: COVID-19 virus test; Result Unstructured Data: Test Result:No - Negative COVID-19 test
CDC Split Type: GBPFIZER INC2021263200

Write-up: Death; This is a spontaneous report from a contactable physician. This is a report received from the Medicines and Healthcare products Regulatory Agency. Regulatory authority report number GB-MHRA-WEBCOVID-202103091343388300, Safety Report Unique Identifier GB-MHRA-ADR 24905509. A 96-years-old female patient received second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) (lot number: ER1741), on 04Mar2021 15:00 at single dose for covid-19 immunisation. Medical history included dementia, significant dementia. Living in a dementia care home. Patient has not had symptoms associated with COVID-19. Concomitant medication included buprenorphine (BUNOV) from 17Sep2019 for Pain, memantine from 09Dec2020 for Dementia, sertraline from 05Feb2020 for Depression. Patient was deteriorating in the days prior to her care homes date for second dose of Pfizer vaccine. End of Life discussions had been had and she was felt to be very likely to die within the next week or two. It was not an unexpected death but it was not felt by the staff at the home to be inappropriate to vaccinate her as the whole care home were receiving their second dose of the vaccine. She was very frail and bed bound and had just in case medications prepared for her. She had her vaccine at about 15.00 on 4Mar2021, and died peacefully at 13:30 the next afternoon on 5Mar2021. The patient experienced death on 05Mar2021 13:30. The lab tests included no - negative covid-19 test on unknown date. The patient died on 05Mar2021. An autopsy was not performed. Patient has not tested positive for COVID-19 since having the vaccine. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: Death


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