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

This is VAERS ID 1142078

Case Details

VAERS ID: 1142078 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: New York  
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-03-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Body temperature increased, Computerised tomogram abdomen abnormal, Computerised tomogram head abnormal, Computerised tomogram pelvis abnormal, Death, Influenza virus test negative, Lung infiltration, Lymphadenopathy, Malaise, Nausea, SARS-CoV-2 test negative, Sepsis, Splenomegaly, Subarachnoid haemorrhage, Unresponsive to stimuli, White blood cell count increased
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zoloft, Xanax, levothyroxine, lovastatin, protonix
Current Illness: None
Preexisting Conditions: Chronic anemia Immune deficiency syndrome hx CLL- dx 1 yrs ago- was on no treatment Hypothyroidism Chronic stable thrombocytopenia with last known platelet count 95,000
Allergies: pyridium
Diagnostic Lab Data: please see narrative above
CDC Split Type:

Write-up: Patient was a high functioning 97-year-old female with a history of CLL diagnosed 1 year ago on no treatment prior to arrival, chronic stable thrombocytopenia, chronic kidney disease, past history of breast cancer and bladder cancer in remission, transfusion dependent anemia of chronic disease, covid 19 vaccination on 3/5/2021, who presented to the emergency room on 3/25/2021 unresponsive found by the family and emergency services was called. The paramedics found her temperature to be 101.6 and her room air sat was 87%. In the ER CT of the head revealed acute subarachnoid hemorrhage. There was no trauma. CT the abdomen and pelvis showed lymphadenopathy and splenomegaly consistent with her known CLL and new bilateral lung infiltrates. Patient''s white blood cell count was 124,000 consistent with her known CLL. Patient prior was high functioning and still drove herself to her doctor''s appointments. The day prior she told her son she was feeling slightly nauseous and ill and went to bed early. She was admitted with a subarachnoid hemorrhage which was felt to be spontaneous and not traumatic. She was not on any anticoagulation prior to arrival. She was also admitted with severe sepsis felt possibly due to aspiration pneumonia or pneumonia in general and she did have fever and bilateral infiltrates on imaging. covid 19 and influenza neg. The decision was made to place her on comfort care after discussion with family. She ultimately expired on 3/28 At 14:48 PM in the presence of her family

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