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

This is VAERS ID 1347081



Case Details

VAERS ID: 1347081 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-04-27
Onset:2021-04-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-05-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 204A21A / 1 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Fatigue, Malaise, Pain in jaw
SMQs:, Osteonecrosis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-24
   Days after onset: 26
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Nicorette Gum
Current Illness:
Preexisting Conditions: Charcot Marie Tooth Disease (form of Muscular Dystrophy) Respiratory Distress hospitalized 3x in 5 years
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient complained of exhaustion and malaise within 24 hours of receiving the dose. This never resolved. Three weeks later he complained of the same exhaustion and malaise. Jaw pain was reported on 5/23/2021. Patient found deceased 5/24/2021 at age of 53.


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