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

This is VAERS ID 1108480

Case Details

VAERS ID: 1108480 (history)  
Form: Version 2.0  
Sex: Male  
Location: Foreign  
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Dehydration, Disturbance in attention, Dyspnoea, Pneumonia bacterial
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Dementia; Renal insufficiency; Type II diabetes mellitus
Diagnostic Lab Data:
CDC Split Type: DEPFIZER INC2021256438

Write-up: Exsiccosis; suspected Pneumonia bacterial; Dyspnoea; Vigilance decreased; This is a spontaneous report downloaded from the Regulatory Authority-WEB DE-PEI-PEI2021003159. This is a report from a non-contactable physician received form Regulatory Authority. An 82-year-old male patient received bnt162b2 (COMIRNATY), via an unspecified route of administration on an unspecified date at single dose for covid-19 immunisation. Medical history included renal insufficiency, dementia, type 2 diabetes mellitus, all from an unknown date and unknown if ongoing. The patient''s concomitant medications were not reported. On 01Feb2021 after vaccination the patient experienced exsiccosis, suspected pneumonia bacterial, dyspnoea, vigilance decreased. It was reported that there were no dyspnoea symptoms until vaccination. The patient was treated with antibiotic therapy. The events were serious as fatal and life threatening. The patient died on 04Feb2021. It was not reported if an autopsy was performed. Health Authority Relatedness of drug to all events: D. Unclassifiable. The information on the batch/lot number has been requested. ; Reported Cause(s) of Death: Exsiccosis; Pneumonia bacterial; Dyspnoea; Vigilance decreased

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