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

This is VAERS ID 1173826

Case Details

VAERS ID: 1173826 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Texas  
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Chest pain, Death, Dyspnoea, Fall, X-ray normal
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Respiratory failure (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: Metformin Amlodipine lasix lovastatin meloxicam lisinopril zofran trazodone fenofibrate
Current Illness:
Preexisting Conditions: Arthritis HTN DM HLD GERD
Allergies: KNA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received the vaccine on 3/9/2021 reports to ED on 3/19/2021 s/p fall while transferring from wheelchair no fractures on x-ray, sent home at 2246. started to c/o chest pain and shortness of breath. Went into cardiac arrest at home approximately 4 hours after leaving ER. Pt was pronounced DOA 3/20/201 @ 0343

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