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

This is VAERS ID 1328778

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Case Details

VAERS ID: 1328778 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Foreign  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Body temperature, Cardiac arrest, Coronary artery stenosis, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-11
   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:
Diagnostic Lab Data: Test Date: 20210511; Test Name: Body temperature; Result Unstructured Data: Test Result:36.2 Centigrade; Comments: before vaccination
CDC Split Type: JPPFIZER INC2021542418

Write-up: Loss of consciousness; Cardiac arrest; Marked coronary artery stenosis; This is a spontaneous report from a contactable physician. This is a report received from the regulatory authority. The regulatory authority report number is v21106100. A 95-year-old female patient received BNT162B2 (COMIRNATY; Lot Number: ER9480, Expiration Date: 31Jul2021), dose 1 via an unspecified route of administration on 11May2021, at 13:45 as 1ST DOSE, single for covid-19 immunization. The patient''s medical history and concomitant medications were not reported. The patient experienced loss of consciousness and cardiac arrest on 11May2021, at 18:40; the patient also experienced marked coronary artery stenosis on 11May2021. The patient underwent lab tests and procedures which included body temperature: 36.2 Centigrade on 11May2021 before vaccination. Details were as follows: On 11May2021 (the day of vaccination), the patient had a light dinner. After the meal, she experienced loss of consciousness while brushing her teeth. Cardiac arrest occurred. Around 19:00, resuscitation was started. The patient underwent tracheal intubation and received drip infusion (LACTEC 500) and BOSMIN 1A intravenously (IV). She was urgently transported to Hospital B and was confirmed dead. On 13May2021 at 09:30, legal autopsy was performed at the hospital. Marked coronary artery stenosis was noted. A diagnosis of death with unknown cause was made. The reporting physician classified the events as serious (per death) and assessed the causality between the events and BNT162b2 as unassessable. Other possible causes of the events such as any other diseases was noted as advanced age. The reporting physician commented as follows: The department of legal medicine would perform further investigation for several months. If no vaccination had been given, heart disorder could be the plausible cause. Therapeutic measures were taken as a result of the events as aforementioned. The patient died on 11May2021.; Reported Cause(s) of Death: Loss of consciousness; Cardiac arrest; Marked coronary artery stenosis

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