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

This is VAERS ID 1784945

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Case Details

VAERS ID: 1784945 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-07-11
Onset:2021-08-02
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0179 / 1 UN / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death, Respiratory tract haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Trisomy 18, Scoliosis, Closed Ventricular Septal Defect, Ectopic Kidney, Gastrostomy Tube dependent, GERD, and Obstructive Sleep Apnea
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Blood in airway, Death


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1784945


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