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

This is VAERS ID 1361500



Case Details

VAERS ID: 1361500 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Maine  
Vaccinated:2021-05-20
Onset:2021-05-26
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-05-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abdominal pain, Blood pressure decreased, Blood test, Cardiac arrest, Computerised tomogram, Death, Electrocardiogram, Fatigue, Intensive care, Organ failure, Pancreatitis acute, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-05-28
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Multi vitamin D3 Vit E Fish Oil Prontonix Potassium Citrate Flomax Lysine Metamucil CoQ10 Tovia Depakote Cymbalta Lipitor Amlodipine Kinopin Qunol
Current Illness: none
Preexisting Conditions: Kidney issues high blood pressure bi polar disorder anxiety high cholesterol
Allergies: amoxicillin tramadol percocet lorazopam
Diagnostic Lab Data: CT scans blood work EKG''s etc.
CDC Split Type:

Write-up: Patient received vaccine on Thursday evening. He began to feel very tired Monday and Tuesday. Wednesday he woke up in alot of abdominal pain. We went to healthcare facility at 4:30pm. He was diagnosed with Acute Pancreatitis. He was sent home at 10:30pm We went back to ED at 1:30 am Thursday. He was admitted during the day. In the early morning of Friday May 28th his blood pressure tanked and he became unresponsive. His heart stopped and they did compressions for 8-9 minutes. He was put into ICU. By 3am we were told he may not survive. By 5 am we were told his organs were shutting down. He passed around 7:45am. In researching the vaccine we discovered the SARS virus used in vaccine can attack the pancreas. We believe he died as a result of the reaction to the vaccine and his body and organs could not fight.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1361500

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