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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1696757

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Case Details

VAERS ID: 1696757 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-09-14
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-09-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA6780 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
SMQs:, 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: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient was 11 years old and 8 months at the time of vaccine No side effects noted.


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