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

This is VAERS ID 1151776

Case Details

VAERS ID: 1151776 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Cardiac failure congestive, Metabolic disorder, Pyrexia
SMQs:, Cardiac failure (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
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: Diabetes mellitus
Diagnostic Lab Data:
CDC Split Type: DEPFIZER INC2021317251

Write-up: Fieber; Decompensated heart failure; Metabolic imbalance in diabetes; This is a spontaneous report received from a non-contactable physician downloaded from the regulatory Agency-WEB. The regulatory authority report number is DE-PEI-PEI2021003619. A 96-year-old male patient received second dose of bnt162b2 (COMIRNATY, Batch/Lot Number: EP9598) via an unspecified route of administration on 08Mar2021 at single dose for covid-19 immunisation. Medical history included diabetes mellitus. Historical Vaccine included first dose of bnt162b2 (COMIRNATY) on 15Feb2021 for covid-19 immunisation, and patient had been tolerated. The patient''s concomitant medications were not reported. The patient experienced fieber, decompensated heart failure, metabolic imbalance in diabetes on 13Mar2021. Events seriousness criteria was death. It was reported that 5 days after vaccination the patient developed Fever and Congestive cardiac failure and Metabolic disorder NOS, lasting for 5 days. The patient died on an unspecified date. It was not reported if an autopsy was performed. Relatedness of drug to all events assessed by PEI as Unclassifiable. No follow-up attempts possible. No further information expected.; Reported Cause(s) of Death: Fieber; Decompensated heart failure; Metabolic imbalance in diabetes

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