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

This is VAERS ID 1439047

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Case Details

VAERS ID: 1439047 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-04-21
Onset:2021-04-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EX0893 / 1 RA / OT

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Chronic obstructive pulmonary disease, Incorrect route of product administration, Infection, Investigation, Respiratory fatigue
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Drug abuse and dependence (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
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: Test Name: Impact on quality of life; Result Unstructured Data: Test Result:10/10
CDC Split Type: ITPFIZER INC2021759368

Write-up: chronic obstructive pulmonary disease; He struggles to breathe infection in progress and then death from cardiocirculatory arrest; infection in progress; cardiocirculatory arrest; received BNT162B2 (COMIRNATY) dose 1 subcutaneous; This is a spontaneous report from a contactable consumer downloaded from the Agency Regulatory Authority-WEB, regulatory authority number IT-MINISAL02-745626. A 65-year-old male patient received BNT162B2 (COMIRNATY) dose 1 subcutaneous on 21Apr2021 (Lot Number: Ex0893) in right arm as dose 1, single for covid-19 immunisation. The patient medical history and concomitant medications were not reported. The patient struggled to breathe, infection in progress and then death from cardiocirculatory arrest on 24Apr2021. The patient had chronic obstructive pulmonary disease on an unspecified date. Impact on quality of life (10/10). The outcome of events struggled to breathe, infection in progress and cardiocirculatory arrest was fatal and other events was unknown. The patient died on an unspecified date. It was not reported if an autopsy was performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: cardiocirculatory arrest; infection in progress; struggled to breathe


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