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From the 10/8/2021 release of VAERS data:

This is VAERS ID 976301

Case Details

VAERS ID: 976301 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Drug ineffective, SARS-CoV-2 test
SMQs:, Lack of efficacy/effect (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   Days after onset: 9
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: Medical History/Concurrent Conditions: Oxygen therapy; Respiratory insufficiency
Diagnostic Lab Data: Test Date: 20201229; Test Name: COVID-19 test; Result Unstructured Data: Test Result:positive
CDC Split Type: DEPFIZER INC2021061184

Write-up: This is a spontaneous report from a physician via the Health Authority. This case is being treated according to the Authorities Protection against Infection Act. Fatal adverse event, ambulatory treatment was required. A contactable physician reported that an 82-year-old male patient received his first dose of bnt162b2 (COMIRNATY, batch/lot number and expiry date: Unknown), via an unspecified route of administration on 29Dec2020 at single dose for Covid-19 immunisation. Medical history included chronic respiratory insufficiency on oxygen concentration therapy. The patient''s concomitant medications were not reported. The patient received the vaccination on 29Dec2020 in the morning. In the afternoon, the COVID-19 test took place. This had a positive result (29Dec2020). His condition continued to deteriorate. He died in the nursing home on 07Jan2021. The cause of death was Acute respiratory insufficiency. There was a questionable connection with the COVID-vaccination. It was not reported if an autopsy was performed. No follow up attempts are possible. Information on the batch number cannot be obtained.; Reported Cause(s) of Death: acute respiratory failure

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