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From the 11/12/2021 release of VAERS data:

This is VAERS ID 1377619

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Case Details

VAERS ID: 1377619 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-05-04
Onset:2021-05-13
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-06-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-13
   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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: DEPFIZER INC2021616446

Write-up: Unknown cause of death; This is a spontaneous report from a non-contactable physician downloaded from a regulatory authority -WEB. The regulatory authority report number is DE-PEI-202100077671. A 79-year-old male patient received BNT162b2 (COMIRNATY, Lot number unknown) via an unspecified route of administration on 04May2021 (at the age of 79-year-old) at single dose for COVID-19 immunisation. Relevant medical history and concomitant medications were not reported. The patient died on 13May2021. Cause of death was unknown. Autopsy was not performed. The causality assessment for suspect drug to event was reported as follows: Source of assessment a regulatory authority. Result of Assessment Unclassifiable. Information about lot/batch number cannot be obtained. No further information expected.; Reported Cause(s) of Death: Unknown cause of death


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