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

This is VAERS ID 1153708

Case Details

VAERS ID: 1153708 (history)  
Form: Version 2.0  
Sex: Female  
Location: Foreign  
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Chest X-ray, SARS-CoV-2 test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Dementia (advanced)
Preexisting Conditions: Comments: Unsure if patient has had symptoms associated with COVID-19 Patient is not enrolled in clinical trial
Diagnostic Lab Data: Test Name: Chest X-ray; Result Unstructured Data: Test Result:unremarkable; Test Date: 20210201; Test Name: COVID-19 virus test; Result Unstructured Data: Test Result:Yes - Positive COVID-19 test
CDC Split Type: GBPFIZER INC2021327159

Write-up: SARS-CoV-2 infection/ Vaccine breakthrough infection; This is a spontaneous report from a contactable healthcare professional. This is a report received from the regulatory authority. Regulatory authority report number GB-MHRA-WEBCOVID-202103231343284950, Safety Report Unique Identifier GB-MHRA-ADR 25005895. An 82-year-old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 19Jan2021 at a single dose for COVID-19 immunisation. Medical history included ongoing dementia (advanced). Unsure if patient has had symptoms associated with COVID-19. She was not enrolled in clinical trial. The patient''s concomitant medications were not reported. The patient experienced SARS-CoV-2 infection and vaccine breakthrough infection on 01Feb2021. The events were assessed as serious by HA (fatal and medically significant). Case narrative: The patient received COVID vaccination 19Jan2021, confirmed COVID positive 01Feb2021. Treated with antibiotics. Chest x-ray unremarkable. Died 13Feb2021. Cause of death 1) advanced dementia and 2) COVID-19. An autopsy was not performed. The patient underwent lab tests and procedures which included COVID-19 virus test: yes - positive COVID-19 test on 01Feb2021. No follow-up attempts are possible. Information about lot/batch number cannot be obtained. No further information is expected.; Reported Cause(s) of Death: Dementia; SARS-CoV-2 infection/ Vaccine breakthrough infection

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