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

This is VAERS ID 1110777



Case Details

VAERS ID: 1110777 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-25
Onset:2021-01-27
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ6788 / 1 - / OT

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

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: Living in care
Preexisting Conditions: Medical History/Concurrent Conditions: Aneurysm of abdominal aorta; Aortic stenosis (loose calcified aortic stenosis); Arterial hypertension; Atrial fibrillation; Duodenal ulcer (moderate intestinal gastritis / duodenal stump ulcer treated with proton-pump inhibitors); Dyslipidaemia; Gastritis (moderate intestinal gastritis / duodenal stump ulcer treated with proton-pump inhibitors); Gastroduodenal anastomosis (partial gastrectomy with gastro-jejunal anastomosis in 1995); Hyperuricaemia (Chronic renal failure with episode of hyperuricaemia); Hypothyroidism (Supplemented hypothyroidism); Ischaemic heart disease; Kidney failure chronic (Chronic renal failure with episode of hyperuricaemia); Livedo reticularis; Mixed dementia; Partial gastrectomy (partial gastrectomy with gastro-jejunal anastomosis in 1995); Peptic ulcer haemorrhage (hemorrhagic peptic ulcers repetitive since 1980); Peripheral arterial occlusive disease; Transient ischemic attack (notion of transient ischemic attack before 2010); Type 2 diabetes mellitus
Allergies:
Diagnostic Lab Data:
CDC Split Type: FRPFIZER INC2021120456

Write-up: Death unexplained; This is a spontaneous report from a contactable physician downloaded from the Regulatory Authority-WEB (Regulatory Authority number: FR-AFSSAPS-CF20210115). An 81-year-old male patient received the first single dose of BNT162B2 (COMIRNATY; lot EJ6788) intramuscular, on 25Jan2021, in early afternoon, for COVID-19 immunisation. The patient was residing in long-term care unit. Medical history included supplemented hypothyroidism, peripheral arterial occlusive disease, kidney failure chronic (chronic renal failure with episode of hyperuricaemia), peptic ulcer haemorrhage (hemorrhagic peptic ulcers repetitive since 1980), atrial fibrillation, type 2 diabetes mellitus, dyslipidaemia, mixed dementia, ischaemic heart disease, arterial hypertension, livedo reticularis, infra-renal abdominal aortic aneurysm in 2007, loose calcified aortic stenosis, notion of transient ischemic attack before 2010, partial gastrectomy with gastro-jejunal anastomosis in 1995, moderate intestinal gastritis / duodenal stump ulcer treated with proton-pump inhibitors. Concomitant medications were not reported. Without any clinical warning sign (absence of oedema, urticaria, respiratory and cardiocirculatory failure), the patient''s death was observed on 27Jan2021 at 17:30 (death unexplained). It was unknown if an autopsy was performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: Death unexplained


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