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

This is VAERS ID 1114039



Case Details

VAERS ID: 1114039 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-29
Onset:2021-01-30
   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 PAA156571 / 1 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: Cardiac failure
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: End stage cardiac failure (for several months); Palliative care (for several months)
Allergies:
Diagnostic Lab Data:
CDC Split Type: FRPFIZER INC2021272340

Write-up: Cardiac failure aggravated; This is a spontaneous report from a contactable physician downloaded from the Regulatory Authority FR-AFSSAPS-DJ20210391 (Regulatory Authority reference) An 89-year-old male patient received the first dose of bnt162b2 (COMIRNATY), Lot PAA156571, intramuscular at single dose in the left arm, on 29Jan2021 for COVID-19 immunisation. Medical history included cardiac failure chronic for several months. Concomitant medications were not reported. On 30Jan2021, the patient experienced cardiac failure aggravated with fata outcome. The patient died on 30Jan2021. An autopsy was not performed. The death was expected for several weeks. This patient was considered to be at risk of developing a severe form of the COVID-19 disease. The patient had not had COVID-19 and had not been tested. After contact with her physician: patient in palliative care for several months. Did not present an immediate post-vaccination problem. Did not have a fever. Had not benefited from any particular monitoring of blood pressure or heart rate given his general condition, which was already very impaired. Reporting taking into account the chronology with a death the day after vaccination. The specific role of the vaccine not clearly retained. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: End stage cardiac failure


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