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

This is VAERS ID 1236493



Case Details

VAERS ID: 1236493 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-06
Onset:2021-01-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ6797 / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, COVID-19, Chills, Cough, Drug ineffective, Dyspnoea, Fatigue, Peripheral circulatory failure, Pyrexia, Somnolence
SMQs:, Anaphylactic reaction (broad), Lack of efficacy/effect (narrow), Interstitial lung disease (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 26
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Arterial hypertension
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: DEPFIZER INC2021409245

Write-up: A.R.D.S.; COVID-19; COVID-19; Dyspnoea; Shivering; Coughing; Fever; peripheral circulatory failure; exhaustion; Groggy; This is a spontaneous report from a non-contactable physician downloaded from the regulatory authority-WEB, regulatory authority number DE-PEI-202100032679. A 61-year-old male patient received bnt162b2 (COMIRNATY), via an unspecified route of administration on 06Jan2021 (Batch/Lot Number: EJ6797) as 0.3 mL, single for COVID -19 immunization. Medical history included ongoing Arterial hypertension. The patient''s concomitant medications were not reported. The patient experienced shivering, fever, exhaustion, groggy, coughing, peripheral circulatory failure on 07Jan2021, Dyspnoea and COVID-19 on 11Jan2021 (both hospitalization), experienced ARDS on 02Feb2021 (hospitalization). The patient died on 02Feb2021 caused by ARDS. An autopsy was not performed. The event outcome was not recovered for shivering, fever, exhaustion, groggy, coughing, peripheral circulatory failure, dyspnoea, COVID-19, fatal for ARDS. No follow-up attempts possible. No further information expected. Information on lot# already obtained.; Reported Cause(s) of Death: ARDS


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