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

This is VAERS ID 1114010



Case Details

VAERS ID: 1114010 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-30
Onset:2021-01-31
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM0477 / 2 - / OT

Administered by: Other       Purchased by: ?
Symptoms: Arrhythmia, Death, Delusion, Disturbance in attention
SMQs:, Dementia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Depression (excl suicide and self injury) (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 3
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: Chronic renal insufficiency; Coronary disease; Hypertension; Type II diabetes mellitus
Preexisting Conditions: Medical History/Concurrent Conditions: Demyelinating disease (excl multiple sclerosis)
Allergies:
Diagnostic Lab Data:
CDC Split Type: DEPFIZER INC2021266953

Write-up: Arrhythmia; Delusion/attention disorders; Delusion/attention disorders; Exitus letalis/cause of death unknown; This is a spontaneous report from a contactable consumer downloaded from the Regulatory Authority [regulatory authority number DE-PEI-CADR2021015311] and [DE-PEI-2021005723]. A 95-year-old male patient received the 2nd dose of bnt162b2 (COMIRNATY, lot number: EM0477) via intramuscular on 30Jan2021 at 0.3 ml single for prophylactic vaccination. Medical history included ongoing coronary disease, ongoing chronic renal insufficiency, ongoing hypertension, ongoing type II diabetes mellitus, demyelinating disease (excl multiple sclerosis) which was unknown if ongoing. Concomitant medications were unknown. The patient previously received the 1st dose of bnt162b2 (COMIRNATY) on 09Jan2021 for Prophylactic vaccination. On 31Jan2021 the patient experienced attention disorders. On 03Feb2021 the patient experienced arrhythmia and cause of death unknown (reported as Exitus letalis). Outcome of the event Exitus letalis/cause of death unknown was fatal, of the other events was unknown. This report was serious - hospitalization. Institution considered that there is an inconsistent causal association to immunization for all three events. Sender Comment: Diab. meel Typ 2 with multiple complications, chron. renal failure, hypertension, coronary heart disease / Exitus letalis. No follow-up attempts possible. No further information expected.; Reported Cause(s) of Death: Unknown cause of death


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