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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1102572



Case Details

VAERS ID: 1102572 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-12
Onset:2021-03-15
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Clobetasol 0.05% topical ointment, fluocinonide 0.05% topical cream, atorvastatin, daily multi-vitamin, glimepiride, metformin, clonidine transdermal, coumadin, folic acid, furosemide, hydralazine
Current Illness: arthritis, atrial fibrillation, congestive heart failure, diabetes mellitus, high cholesterol levels, hypertension
Preexisting Conditions: aortic valve replacement
Allergies: no known drug allergies
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Was notified by a third party that patient died on morning of 3/15/2021. No other information available.


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