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

This is VAERS ID 1110775



Case Details

VAERS ID: 1110775 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-01-12
Onset:2021-01-25
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM0477 / 1 - / OT

Administered by: Other       Purchased by: ?
Symptoms: Death, Oxygen saturation decreased
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: LEVODOPA BENSERAZIDE; DIFFU K; PARACETAMOL; LACTULOSE; GLUCOSE
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Bedridden; Dementia
Allergies:
Diagnostic Lab Data:
CDC Split Type: FRPFIZER INC2021120418

Write-up: Death unexplained; Oxygen saturation decreased; This is a spontaneous report from a contactable Pharmacist downloaded from the regulatory authority-WEB FR-AFSSAPS-AN20210159. A 86-years-old female patient received the first dose of bnt162b2 (COMIRNATY; Lot # EM0477) vaccine , intramuscular on 12Jan2021 at single dose for Covid-19 immunisation . Medical history included dementia, bedridden . Concomitant medication included benserazide hydrochloride, levodopa (LEVODOPA BENSERAZIDE), potassium chloride (DIFFU K), paracetamol (PARACETAMOL), lactulose (LACTULOSE), glucose (GLUCOSE). The patient experienced death unexplained on 27Jan2021 , oxygen saturation decreased from 25Jan2021 to death. The patient was vaccinated against COVID-19 by a first injection of COMIRNATY on 12Jan2021. No immediate reaction reported after vaccination. No hyperthermia episode. This was a bedridden patient living in a nursing home and who has been eating little since January. The patient''s condition has deteriorated since the end of November 2020. On 19Jan2021, the examination of the patient was very difficult, the patient was also non-dyspneic. On 25Jan2021, it presented a deterioration of the general condition and a desaturation. The patient died of unknown cause on 27Jan2021. An autopsy was not performed. No follow-up attempts are possible, batch number already obtained.; Reported Cause(s) of Death: Death unexplained


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