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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1100865



Case Details

VAERS ID: 1100865 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-13
Onset:2021-03-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   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: Cefuroxime, Lansoprazole, Sulfasalazine, Azulfidine, Amoxicillin, Lisinopril, Fluticasone Nasal Spray, Tenormin, Atenolol,
Current Illness: Hospitalized for Pneumonia 2-8-2021
Preexisting Conditions: Hypertension, obesity
Allergies: Unknown
Diagnostic Lab Data: Decedent is currently at facility awaiting further examination/investigation.
CDC Split Type:

Write-up: Patient died within 24 hours of vaccine. Unknown at this time if related.


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