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

This is VAERS ID 1113904



Case Details

VAERS ID: 1113904 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-02-01
Onset:2021-02-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ6790 / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: DUROFERON; VISCOTEARS; SERTRALINE; MIRTAZAPINE; XALATAN; SALBUTAMOL SULFATE]; QUETIAPINE; PARACETAMOL; SYMBICORT TURBUHALER; ORIVAST; OESTRIOL; INNOVAIR
Current Illness: COVID-19 (declared healthy from COVID 19 10 days before the vaccine)
Preexisting Conditions: Medical History/Concurrent Conditions: Asthma; Glaucoma; Mixed dementia; Renal failure (stage 2)
Allergies:
Diagnostic Lab Data:
CDC Split Type: SEPFIZER INC2021256599

Write-up: DEATH; This is a spontaneous report from a contactable physician downloaded from the Agency Regulatory authority-WEB, Regulatory authority number SE-MPA-2021-008343 and additional case identifier SE-MPA-1614245793874. A 95-year-old female patient received the first dose of BNT162B2 (COMIRNATY, Lot number EJ6790), via an unspecified route of administration, in Feb2021 at 0.3 mL single for COVID-19 immunisation. Relevant medical history included COVID-19 from Jan2021 to Feb2021 (declared healthy from COVID 19 10 days before the vaccine); mixed dementia, renal failure stage 2, asthma and glaucoma, from an unknown date and unknown if ongoing. Relevant concomitant medications included ferrous sulfate (DUROFERON) in Feb2021, carbomer (VISCOTEARS) from Oct2020 to Feb2021, sertraline from Oct2019 to Feb2021, mirtazapine from Dec2019 to Feb2021, latanoprost (XALATAN) from Mar2020 to Feb2021, salbutamol sulfate (VENTOLINE) from Nov2019 to Jan2021, quetiapine from Jan2020 to Feb2021, paracetamol from Dec2019 to Feb2021, budesonide, formoterol fumarate (SYMBICORT TURBUHALER) from Apr2019 to Jan2021, rivastigmine (ORIVAST) from May2020 to Feb2021, oestriol (OESTRIOL) from Nov2019 to Feb2021, and beclometasone dipropionate, formoterol fumarate (INNOVAIR), from Jan2021 to Feb2021. The patient was mobile and alert when she received the first dose of BNT162B2 (COMIRNATY). After this, the patient deteriorated and died two days after the vaccination. 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


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