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

This is VAERS ID 1110758



Case Details

VAERS ID: 1110758 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2020-12-29
Onset:2021-01-03
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Death, Drug ineffective, SARS-CoV-2 test
SMQs:, Lack of efficacy/effect (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   Days after onset: 0
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: SARS-CoV-2 test; Result Unstructured Data: Test Result:Positive
CDC Split Type: DEPFIZER INC2021125922

Write-up: positive COVID-19 test with symptoms; positive COVID-19 test with symptoms; death; This is a spontaneous report from a contactable other hcp based on information received by Pfizer from Biontech (manufacturer control number unknwn), license partner for COMIRNATY. A 85-year-old female patient received bnt162b2 (COMIRNATY), via an unspecified route of administration on 29Dec2020 at single dose for covid-19 vaccination. The patient medical history and the patient''s concomitant medications were not reported. The patient had a positive covid-test on an unspecified date, typical symptoms and died on 03Jan2021. It was not reported if an autopsy was performed. The patient was vaccinated prior to her death. According to the staff of the hospital, the patient received a positive COVID-Test on the day of her death, after she had developed typical symptoms 2 days prior and therefore was switched to the "Covid-Station" of the nursing home. Over the further cause the vaccination symptoms increased and the patient died. Information about batch number was not available and is going to be requested.; Sender''s Comments: Death of unknown cause is assessed related as a cautionary measure and for reporting purposes. Based on the information available, a possible contributory role of the suspect BNT162B2 cannot be excluded for the reported positive COVID-Test based on the known safety profile. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: Unknown cause of death


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