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

This is VAERS ID 1188278



Case Details

VAERS ID: 1188278 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-03-06
Onset:2021-03-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / UNK - / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardioversion, Pulse absent, Resuscitation, Sudden death, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   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: Atenolol, Synthroid, Lisinopril, Zocor, Gabapentin, Allopurinal, AREDS eye pills, CoQ10, Norco
Current Illness: HTN, arthritis, chronic low grade B cell lymphoma, asthma, severe seasonal allergies plus other allergies to dogs, cats, mold, pollen etc., stent to carotid artery after surgical scar weakened
Preexisting Conditions: See above. No illness at time of vaccine
Allergies: No
Diagnostic Lab Data: ER doctor stated he had enough risk factors to experience sudden death. I also realize he had risk factors but since all these reports are coming out about blood clots occuring I thought I should report it.
CDC Split Type:

Write-up: Patient collapsed & died 48 hrs. after receiving vaccine. He was shopping at local CVS store & collapsed without warning. Two nurses on scene at Clinic performed CPR immediately & applied AED. EMS arrived within 5 min. There was never a heart rhythm & after 35 min. of CPR was DOA at hospital ER. He had gone to the gym earlier at 7am & was having a normal day. He had not mentioned any complaints of not feeling well.


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