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

This is VAERS ID 1153652



Case Details

VAERS ID: 1153652 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-01-27
Onset:2021-01-31
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ9795 / 2 - / OT

Administered by: Other       Purchased by: ?
Symptoms: Cardio-respiratory arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: Arrhythmia supraventricular; Cognitive disturbance; Hypertension arterial; Ischaemic heart disease
Allergies:
Diagnostic Lab Data:
CDC Split Type: FRPFIZER INC2021311540

Write-up: Cardio-respiratory arrest; This is a spontaneous report from a contactable physician downloaded from the regulatory authorian. This is a report received from the Regulatory Authority. An 87-year-old female patient received the second dose of BNT162B2 (COMIRNATY), intramuscular on 27Jan2021 (lot number: EJ9795) as single dose for COVID-19 vaccination. The patient''s medical history included ischaemic heart disease, arrhythmia supraventricular, cognitive disturbance, and hypertension arterial. The patient''s concomitant medications were not reported. The patient previously took the first dose of BNT162B2 (COMIRNATY) on 06Jan2021 for COVID-19 immunisation. The patient died due to cardio-respiratory arrest on 31Jan2021. It was not reported if an autopsy was performed.; Reported Cause(s) of Death: Cardio-respiratory arrest


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