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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1170462



Case Details

VAERS ID: 1170462 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Nevada  
Vaccinated:2021-03-31
Onset:2021-04-05
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808978 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Malaise, Rash, Rash erythematous, Rash macular, Rash papular
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   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: Naprosyn, Atenolol, Nitroglycerine, Tamsulosin, omeprazole, KCL, finesteride
Current Illness: Stasis dermatitis, GERD, HTN, chronic LBP.
Preexisting Conditions: HTN
Allergies: IBU, clindamycin, Bactrim, ASA, Robaxin,
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Presented with rash and malaise "since I got my COVID shot". Rash red raised macular t/o body


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1170462


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