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

This is VAERS ID 1198227



Case Details

VAERS ID: 1198227 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-04-05
Onset:2021-04-07
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 043A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Fluid intake reduced, Incoherent, Influenza like illness
SMQs:, Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-09
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ISOSORBIDE MONONITRATE 30MG, TELMISARTAN 80MG, HYDRALAZINE 100MG, OMEPRAZOLE 20MG, PREDNISONE 1MG, METHOTREXATE 25MG/ML INJ, ATORVASTATIN 80MG, LANTUS, NOVOLOG
Current Illness:
Preexisting Conditions: DIABETES, ARTHRITIS, HEART
Allergies: NKA
Diagnostic Lab Data: CONTACT HOSPITAL FOR INFORMATION
CDC Split Type:

Write-up: SON REPORTED THAT PATIENT WOKE UP 4/7/21 WITH FLU LIKE SYMPTOMS AND STAYED IN BED ALL DAY. PT DID NOT DRINK ANYTHING OR TAKE INSULIN ON 4/7/21. WHEN DAUGHTER ARRIVED AT PTS HOME THAT EVENING, PT WAS INCOHERENT. SHE CALLED 911 AND PT WAS TRANSPORTED TO THE HOSPITAL WHERE HE PASSED AWAY ON 4/9/21.


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