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

This is VAERS ID 1124688



Case Details

VAERS ID: 1124688 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-17
Onset:2021-03-20
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN N/A / 1 UN / UN

Administered by: Private       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   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: Atorvastatin, Levothyroxine, Novolog, Iron ,Lisinopril, Aspirin,
Current Illness: Insulin Dependent DM, HTN, Hypercholesterolemia, Underweight, Hypothyroidism
Preexisting Conditions: As above
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Sudden death March 20, 2021


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1124688


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