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

This is VAERS ID 1177248



Case Details

VAERS ID: 1177248 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-04-02
Onset:2021-04-04
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805031 / N/A LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Chills, Malaise, Pyrexia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Alpahgan P 0.1% eye drops Amlodipine 5mg tablet Aspirin 81 mg tablet Delayed release Betimol 0.5% eye drops Calmoseptine 0.44%-20.6% topical ointment Carvedilol 12.5 mg tablet Hydralazine 50mg tablet lidocaine-prilocaine 2.5%-2.5% topical
Current Illness: none that I am aware of.
Preexisting Conditions: Patient was placed on Hospice care the week of 3/29/2021.
Allergies: Betadine- skin rash
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Family reports general malaise post treatment, followed by fever and chills 4/3/2021, and cardiac arrest 4/4/2021.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1177248


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