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

This is VAERS ID 1273691



Case Details

VAERS ID: 1273691 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-03-11
Onset:2021-03-24
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805018 / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Death, Multiple organ dysfunction syndrome, SARS-CoV-2 test positive, Shock haemorrhagic
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-19
   Days after onset: 26
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 26 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient tested positive for COVID 19 on 03/21 after a symptom onset of 03/19/21. She was admitted to the hospital on 03/24 and passed away 04/19. Cause of death is listed as multi-organ dysfunction secondary to hemorrhagic shock, other contributing factors: COVID-19 pneumonia.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1273691

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