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From the 4/30/2021 release of VAERS data:

This is VAERS ID 1112701



Case Details

VAERS ID: 1112701 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-03-12
Onset:2021-03-15
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   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: warfarin, famotidine
Current Illness:
Preexisting Conditions:
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received COVID19 shot on 3/12/2021. Pt passed away on 3/15/2021. Dr called us to inform us that our patient had passed away but he did not believe it was caused by the vaccination at this time.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1112701


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