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

This is VAERS ID 1175492

Case Details

VAERS ID: 1175492 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Kentucky  
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Atrial fibrillation, COVID-19 pneumonia, Chronic obstructive pulmonary disease, Condition aggravated, SARS-CoV-2 test positive
SMQs:, Supraventricular tachyarrhythmias (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: COVID-19 infection
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: Tested positive for COVID-19 on 3/17/2021.
CDC Split Type:

Write-up: Janssen vaccine given on 3/9/2021; Admitted to the hospital on 3/16/2021 for COVID-19 infection, pneumonia, new onset a-fib, and COPD exacerbation.

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