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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1114058

Case Details

VAERS ID: 1114058 (history)  
Form: Version 2.0  
Sex: Female  
Location: Foreign  
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory failure, Cardiac failure, Dyspnoea, Pulmonary embolism, Respiratory distress, SARS-CoV-2 test
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Heart failure; Ischaemic cardiomyopathy (under pacemaker); Mild neurocognitive disorder (moderate neurocognitive disorder)
Preexisting Conditions: Medical History/Concurrent Conditions: Dysrhythmias; Ischemic heart disease (under pacemaker)
Diagnostic Lab Data: Test Date: 20210218; Test Name: COVID-19 test; Test Result: Negative
CDC Split Type: FRPFIZER INC2021272412

Write-up: Acute respiratory decompensation; Dyspnea; Cardiac decompensation with suspected pulmonary embolism; Cardiac decompensation with suspected pulmonary embolism; Respiratory distress; This is a spontaneous report downloaded from the Agency Regulatory Agency-WEB [FR-AFSSAPS- RN20210588] and received via the Agency . A contactable physician reported that an 89-year-old female patient received second dose of bnt162b2 (COMIRNATY, Formulation: Solution for injection, Lot number: EJ6789), intramuscularly in right arm on 05Feb2021 at single dose for COVID-19 immunisation. The patient''s medical history included ongoing mild neurocognitive disorder/ moderate neurocognitive disorder, ongoing heart failure, ongoing ischaemic cardiomyopathy under pacemaker, ischemic heart disease under pacemaker, dysrhythmic. The patient had no history of COVID-19. Concomitant medications were not reported. The patient experienced acute respiratory decompensation, dyspnea, cardiac decompensation with suspected pulmonary embolism, respiratory distress on 17Feb2021. On 18Feb2021, a COVID-19 test was performed, and it was negative. The patient condition required urgent medical intervention. The events acute respiratory decompensation, dyspnea, cardiac decompensation were considered as serious (death) by the physician. The outcome of the events pulmonary embolism, respiratory distress was unknown and fatal for the other events. The patient died on 22Feb2021. It was not reported if an autopsy was performed or not. Comment: Case from a report via the portal (# 20210222150517211), medically confirmed. No follow-up attempts needed. No further information expected.; Reported Cause(s) of Death: Acute respiratory decompensation; Dyspnea; Cardiac decompensation with suspected pulmonary embolism

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