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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1222868

Case Details

VAERS ID: 1222868 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Puerto Rico  
   Days after vaccination:8
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: COVID-19, Condition aggravated, Cough, Death, Heart rate increased, Hypotension, Lung disorder
SMQs:, Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-14
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Phenacyl, Zoloft, Aspirin, Lorazepam, Losartan, Metformin, Eloupramide, Lasix
Current Illness: None reported
Preexisting Conditions: Diabetes, amputation in one limb, hypertension, cardiovascular, lung problems and dementia.
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-108-21

Write-up: According to POC the resident was transferred to the hospital on 4/8/2021, due to low pressures, high pulse and cough. They certify death by COVID 19, because it affected the lungs.

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