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

This is VAERS ID 1124100



Case Details

VAERS ID: 1124100 (history)  
Form: Version 2.0  
Age: 103.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-26
Onset:2021-03-16
   Days after vaccination:49
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   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:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: NA - Reaction Age 103.dementia


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1124100

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