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

This is VAERS ID 1114011



Case Details

VAERS ID: 1114011 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-01-25
Onset:2021-02-05
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNKNOWN / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Arrhythmia, Death, Dysphonia, Feeling cold, Tachycardia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Parkinson-like events (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
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: Acute cardiac insufficiency; Chronic renal insufficiency
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: DEPFIZER INC2021266952

Write-up: Chilliness/freezing; Vocal tone disorder; Arrhythmia; Tachycardia; Unknown cause of death; This is a spontaneous report received from a contactable consumer downloaded from the Regulatory Authority [DE-PEI-CADR2021017275]. An elderly female patient of an unspecified age received the BNT162B2 (COMIRNATY, lot number unknown), via an unspecified route of administration, on 25Jan2021, at single dose, for COVID-19 immunization. Medical history included ongoing acute cardiac insufficiency and chronic renal insufficiency. The concomitant medications were not reported. On 05Feb2021 the patient experienced unknown cause of death. It was not reported if an autopsy was performed. The patient also experienced arrhythmia, tachycardia, chilliness/freezing, vocal tone disorder. This report was provided as serious (hospitalization). The outcome of event "unknown cause of death" was fatal; of other events was not recovered. Sender''s Comment: Information on risk factors or previous illnesses I stated: cardiac and renal insufficiency, marcumar patient. / The general health deteriorated rapidly. Health condition and vaccination response were too much. One should have recognized that. As the caring daughter, I stated on the form that I give consent to the vaccination if it was medically justifiable. I had doubts. But it was vaccinated in rows of three, according to my mother, a doctor consultation did not take place. I had to sign a form dated 22Dec2020 and a new one dated 18Jan2021. So far I have been vaccinated confidently, most recently the Schingrix vaccination. But my trust is destroyed. I will only get vaccinated by my family doctor after thorough consultation. Everything is still too early and has not been tested. Too many old people died soon after vaccination. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Unknown cause of death


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