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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1380535

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Case Details

VAERS ID: 1380535 (history)  
Form: Version 2.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Chills, Haematoma, Pain in extremity, Pallor
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-01
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Limb ischaemia (Chronic lower limb ischaemia); Triple vessel bypass graft; Type 2 diabetes mellitus
Diagnostic Lab Data:
CDC Split Type: SKPFIZER INC2021617816

Write-up: Pallor of skin; haematoma of left arm; Shivering; pain of whole upper left extremity; This is a spontaneous report from a contactable physician downloaded from the Regulatory Authority-WEB, regulatory authority number SK-SUKLSK-20214306. An 87-year-old male patient received his first dose of BNT162B2 (COMIRNATY) (tozinameran, Batch/lot number ET6956) intramuscular on 27Apr2021 for Covid-19 immunization. Relevant medical history included triple vessel bypass graft, type 2 diabetes mellitus and chronic lower limb ischaemia. Concomitant medications were not reported. On 28Apr2021 the patient experienced tremor (shivering), pale skin, hematoma of two thirds of the left shoulder, pain of the whole left upper limb. On 30Apr2021 around 16:00 there was an escalation of shoulder pain and patient''s relatives transported him to the hospital, admitted for hospitalization. On 01May2021 at 08:50 a.m. the patient was pronounced as dead. After death the autopsy was not done. The physician has little information on cause of death, "the only available reported information were from inspection of a body after death: Ia: Heart failure, unspecified, Ic: Chronic ischaemic heart disease, II: Poisoning by anticoagulant antagonists (vitamin K)". The outcome of all events was reported as fatal. Sender Comment: Because of insufficient information on this case and missing autopsy, the causal relationship can not be assess. The physician was not able to assess the causality because of little information on this case and missing autopsy. The physician considered the time relationship to vaccine administration. No follow-up attempts possible. No further information expected.; Reported Cause(s) of Death: pain of whole upper left extremity; pallor of skin; hematoma of left arm; Shivering

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