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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1222852

Case Details

VAERS ID: 1222852 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Female  
Location: Puerto Rico  
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cough, Decreased appetite, Dysphagia
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol, Metformin, Sitalopram, Amlodipine, Losartan, Idrocolozid, Synthroid, Isosorbide
Current Illness: None reported
Preexisting Conditions: Hypertensive, diabetic, sinusitis, Alzheimer''s
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-107-21

Write-up: The manager says the patient lost her appetite, presented a cough with difficulty swallowing

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