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

This is VAERS ID 1579810

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Case Details

VAERS ID: 1579810 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-06-04
Onset:2021-06-20
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-08-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / OT

Administered by: Other       Purchased by: ?
Symptoms: Aortic rupture, Cardiac arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-20
   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: JPPFIZER INC202100987495

Write-up: aortic rupture; cardiac arrest; This is a spontaneous report from a contactable physician received via a Pfizer employee. A 93-year-old female patient received BNT162B2 (COMIRNATY, solution for injection, lot number and expiry date were not reported), intramuscularly on 04Jun2021 as dose number unknown, 0.3 mL single for COVID-19 immunization. The patient''s medical history and concomitant medications were not reported. The patient experienced aortic rupture and cardiac arrest on 20Jun2021. The clinical course was as follows: On 04Jun2021, the patient received Comirnaty. It had passed without any problems. On 20Jun2021, the patient died from cardiac arrest due to aortic rupture at the facility that the patient went for a short stay. The cause of death was aortic rupture. The patient died on 20Jun2021. It was not reported if an autopsy was performed and the reported causes of death were aortic rupture and cardiac arrest. The reporting physician commented as follows: It had passed more than two weeks after the vaccination, and the causality was unknown. The lot number for BNT162b2 was not provided and will be requested during follow up.; Reported Cause(s) of Death: aortic rupture; cardiac arrest


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