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

This is VAERS ID 1110776



Case Details

VAERS ID: 1110776 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-06
Onset:2021-01-27
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / OT

Administered by: Other       Purchased by: ?
Symptoms: Blood creatine, C-reactive protein, Death, Haemoglobin, SARS-CoV-2 test, White blood cell count
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Cataract bilateral NOS; Prostate adenoma
Allergies:
Diagnostic Lab Data: Test Date: 20210113; Test Name: Leukocytes; Result Unstructured Data: Test Result:7.58 g/l; Test Date: 20201208; Test Name: Creatinine; Result Unstructured Data: Test Result:176 umol/l; Test Date: 20201214; Test Name: Creatinine; Result Unstructured Data: Test Result:153 umol/l; Test Date: 20201223; Test Name: Creatinine; Result Unstructured Data: Test Result:22 umol/l; Test Date: 20201230; Test Name: Creatinine; Result Unstructured Data: Test Result:255 umol/l; Test Date: 20210106; Test Name: Creatinine; Result Unstructured Data: Test Result:258 umol/l; Test Date: 20210113; Test Name: Creatinine; Result Unstructured Data: Test Result:343 umol/l; Test Date: 20210106; Test Name: CRP; Result Unstructured Data: Test Result:<4 mg/l; Test Date: 20201230; Test Name: hemoglobin; Result Unstructured Data: Test Result:10.7 g/dl; Test Date: 20210106; Test Name: hemoglobin; Result Unstructured Data: Test Result:9.6 g/dl; Test Date: 20210113; Test Name: hemoglobin; Result Unstructured Data: Test Result:3.04 g/dl; Test Date: 20201231; Test Name: PCR SARS-COV 2; Result Unstructured Data: Test Result:undetectable; Test Date: 20201230; Test Name: Leukocytes; Result Unstructured Data: Test Result:9.84 g/l; Test Date: 20210106; Test Name: Leukocytes; Result Unstructured Data: Test Result:6.11 g/l
CDC Split Type: FRPFIZER INC2021120401

Write-up: Death unexplained; This is a spontaneous report from a contactable physician from the Regulatory Authority-WEB FR-AFSSAPS-AN20210164. An 86-year-old male patient received bnt162b2 (COMIRNATY) , intramuscular at single dose on 06Jan2021 for Covid-19 immunisation (in comfort care for months). Medical history included cataract bilateral nos and prostate adenoma. Concomitant medications were not reported. The patient experienced death unexplained on 27Jan2021. Course of the event as follows: Around 20Jan2021, deterioration of the general condition. Rapidly progressing renal failure managed in a palliative manner. Patient died on 27Jan2021. An autopsy was not performed. Declaration of pharmacovigilance in principle, not related to the supposed vaccination because pre-existing severe condition. The patient underwent lab tests and procedures which included Creatinine (?mol / L): 153 (14Dec2020), 176 (08Dec2020), 22 (23Dec2020), 255 (30Dec2020), 258 (06Jan2021) 343 (13Jan2021); Leukocytes (G / L) 9.84 (30Dec2020), 6.11 (06Jan2021), 7.58 (13Jan2021); Hemoglobin (g / dL): 10.7 (30Dec2020), 9.6 (06Jan2021), 3.04 (13Jan2021); CRP: <4mg / L on 06Jan2021; PCR SARS-COV 2 undetectable on 31Dec2020. No follow-up attempts possible. No further information expected, information about lot/batch number cannot be obtained.; Sender''s Comments: Based on the current available information, the event Death unexplained is most likely related to an intercurrent or underlying condition which is not related to the suspect product BNT162B2. The case will be reassessed if additional information becomes available.; Reported Cause(s) of Death: Death unexplained


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