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

This is VAERS ID 1155893

Case Details

VAERS ID: 1155893 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: New York  
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808978 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chills, Death, Myalgia, Pyrexia
SMQs:, Rhabdomyolysis/myopathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: Tramadol HCl 50 Tablet Taking Lisinopril 40 MG Tablet Taking Allopurinol 100 Tablet Taking Atorvastatin Calcium 80 MG Tablet Taking Coumadin 7.5 MG Tablet Taking Desmopressin Acetate Spray Taking Atenolol 100 MG Tablet
Current Illness:
Preexisting Conditions: paroxysmal Atrial fib- stable, INR, 2.7, Last stress test normal (more than 10 mets no difficulty) Diabetes stable Hga1c 6.4% Pituitary adenoma
Diagnostic Lab Data: none. Last INR 2.7 Hga1c 6.4%
CDC Split Type:

Write-up: pt was at his normal baseline of health the Monday of vaccine. Per sister, he had a fever of 104F, chills and myalgias hte following Saturday. he was not heard from on Sunday therefore on Monday his sister did a forced entry and found him on the ground.

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