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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1318093

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Case Details

VAERS ID: 1318093 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-02-04
Onset:2021-04-26
   Days after vaccination:81
Submitted: 0000-00-00
Entered: 2021-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9788 / 2 - / OT

Administered by: Other       Purchased by: ?
Symptoms: Body temperature, COVID-19, SARS-CoV-2 test, Vaccination failure
SMQs:, Lack of efficacy/effect (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-02
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ACIDUM FOLICUM; ATORVASTATIN; BISOCE; FUROSEMIDE; METFORMIN; NEO MERCAZOLE; OLANZAPINE; RAMIPRIL; VITABACT; XARELTO
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Atrial fibrillation; Cardiac failure (Heart failure); Diabetes; Hypertension arterial (High blood pressure); Hyperthyroidism; Infarct myocardial
Allergies:
Diagnostic Lab Data: Test Date: 20210502; Test Name: body temperature; Result Unstructured Data: Test Result:39 Centigrade; Test Date: 20210426; Test Name: PCR test; Test Result: Positive
CDC Split Type: FRPFIZER INC2021521574

Write-up: Vaccination failure; COVID-19 PCR test positive; This is a spontaneous report from a contactable consumer downloaded from the Regulatory Authority-WEB, regulatory authority number FR-AFSSAPS-DJ20211042, Safety Report Unique Identifier FR-AFSSAPS-2021047636. An 83-year-old male patient received BNT162B2 (COMIRNATY), intramuscular on 04Feb2021 (batch/lot number: EK9788) as 2nd dose, single, and intramuscular on 14Jan2021 (batch/lot number: EM0477) as 1st dose, single for COVID-19 vaccination. Medical history included hyperthyroidism, hypertension arterial (high blood pressure), atrial fibrillation, infarct myocardial, diabetes and cardiac failure (heart failure). Concomitant medications included acidum folicum, atorvastatin, bisoprolol fumarate (BISOCE), furosemide, metformin, carbimazole (NEO MERCAZOLE), olanzapine, ramipril, picloxydine dihydrochloride (VITABACT) and rivaroxaban (XARELTO). The patient experienced vaccination failure and COVID-19 PCR test positive on 26Apr2021 with fatal outcome. It was further reported that PCR positive on 26Apr2021. He presented flu-like symptoms on 01May2021 and died on 02May2021. On the day of death the symptoms were fever of 39 degrees, asthenia and spasms. No variant identified. Context of several cases in the same nursing home (cf DJ20211054 + other case under documentation). In total: 83-year-old patient who presented with a vaccine failure and died at the nursing home on 02May2021. A drug was substantially coded if the name of the specialty was not known. The outcome of the rest of the events was unknown. The patient died on 02May2021. An autopsy was not performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: COVID-19 PCR test positive; Vaccination failure


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