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

This is VAERS ID 1229214



Case Details

VAERS ID: 1229214 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: New York  
Vaccinated:2021-04-09
Onset:2021-04-13
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 205A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: LABETALOL 300MG LEVETIRACETAM 750MG ATORVASTATIN 20MG TELMISARTAN 80MG ASPIRIN 81MG
Current Illness: NONE KNOWN
Preexisting Conditions: AS PER MEDICATIONS ABOVE
Allergies: NKA
Diagnostic Lab Data: WE DON''T KNOW
CDC Split Type:

Write-up: WE RECEIVED A CALL ON TUESDAY AFTERNOON THE 13TH OF APRIL FROM THE MEDICAL EXAMINER REQUIRING INFORMATION ON HOW TO CONTACTB THE PATIENT''S DOCTOR. WHEN ASKED AS TO WHAT HAPPENED WE WERE TOLD THAT THE PATIENT WAS FOUND DEAD IN HER APARTMENT ON TUESDA.Y. WE DID INFORM THEM THAT THE PATIENT HAD RECEIVED THE JANSSEN VACCINE AT THE PHARMACY ON FRIDAY THE 9TH. WE DONT KNOW THE CAUSE OF ADVERSE EVENT.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1229214

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