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

This is VAERS ID 1187758



Case Details

VAERS ID: 1187758 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-04-09
Onset:2021-04-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 205A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Tremor
SMQs:, Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-09
   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: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT WAS GIVEN JANSSEN COVID 19 VACCINE AT AROUND 12PM WHEN PATIENT WAS ACCOMPANIED BY HIS SON. HE WAS OBSERVED FOR 15 MINUTES AFTER THE VACCINATION AND LEFT PHARMACY WITHOUT ANY PROBLEM. PATIENT''S DAUGHTER CALLED AROUND 6PM AND REPORTED HER FATHER JUST DIED. SHE REPORTED HER FATHER ALL OF SUDDEN WAS SHAKING AND DIED RIGHT AFTER.


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