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

This is VAERS ID 1223644



Case Details

VAERS ID: 1223644 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-04-02
Onset:2021-04-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 AR / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abdominal pain upper, Death, Fatigue, Malaise
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Norco, Uptravi, Eliquis, Metoprolol Tartrate, Torsemide, Klor-con, Duloxatine, Iron tablet, Nexium, vitamin B12 sublingual, Breo Ellipta, men?s multivitamin w/D3, N-acetyl L-cysteine, Singulair, DHEA supplement, Vitamin A, Zinc, Duo Neb (HH
Current Illness: None
Preexisting Conditions: Asbestosis, Atrial fib, congestive heart failure, gastritis, PAH, sleep apnea
Allergies: Atavan, Dilaudid IV, Fentenyl IV, Gabapentin/Lyrica, Tegaderm dressing, silk tape
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Not feeling well, malaise, fatigue, intermittent upper stomach pain (sharp) beginning day after vaccine administration lasting 8 days resulting in death on 4/10/21


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1223644

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