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

This is VAERS ID 1270690



Case Details

VAERS ID: 1270690 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-04-08
Onset:2021-04-15
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19 pneumonia, Chest X-ray abnormal, Computerised tomogram thorax abnormal, Death, Dyspnoea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-27
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Abilify, Indapamide, Citalopram, Buspirone, Simvastatin, Vitamin B12, Wellbutrin, Albuterol, Losartan, Metoprolol, Advair, Vitamin D, Levothyroxine, Toviaz, Nexium, Aspirin
Current Illness: none
Preexisting Conditions: OSA, Osteoporosis, HTN, GAD, Hyperlipid, GERD, Obesity, Depression
Allergies: Amoxicillin
Diagnostic Lab Data: CXR, CT Chest
CDC Split Type:

Write-up: Patient developed shortness of breath 3 days post injection. Death due to COVID-19 pneumonia 4/27/21


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1270690

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