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

This is VAERS ID 1109821

Case Details

VAERS ID: 1109821 (history)  
Form: Version 2.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Cardiac failure, Dyspnoea, Nasopharyngitis
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 22
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data:
CDC Split Type: FIPFIZER INC2021256364

Write-up: Cold symptoms; Dyspnoea; Cardiac insufficiency; This is a spontaneous report from a contactable physician downloaded from The Regulatory Authority-WEB FI-FIMEA-20211043. This is a report from Regulatory Authority. A 92-year-old male patient received bnt162b2 (COMIRNATY) (lot EJ6134) second dose intramuscular on 21Jan2021 at single dose for covid-19 immunisation. The patient medical history was not reported. Concomitant medication included salbutamol (VENTOLINE), bisoprolol, rivaroxaban (XARELTO), ramipril, furosemide (FURESIS). The patient experienced cold symptoms, dyspnoea and cardiac insufficiency on 05Feb2021. The patient developed dyspnea which was seen as a symptom of a cold. The symptoms of a cold eased but the dyspnea still persisted. The patient''s functional capacity decreased and the patient was admitted to the hospital ward due to worsening of cardiac insufficiency. The correlation between the symptoms and the received vaccination is unclear, but the symptoms started after the patient received the vaccine and there was no clear reason for the dyspnea, so a suspicion was raised of a possible reaction caused by the vaccine. The patient died on 27Feb2021. It was not reported if an autopsy was performed. Follow-up attempts not possible. No further information expected.; Reported Cause(s) of Death: Cold symptoms; Dyspnoea; Cardiac insufficiency

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