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

This is VAERS ID 1361961

Case Details

VAERS ID: 1361961 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Vermont  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808982 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Brain natriuretic peptide, Culture urine positive, Death, Decreased appetite, Diet refusal, Fatigue, Feeling hot, Full blood count, Metabolic function test, Nervousness, Oedema peripheral, Pain, Pleural effusion, Somnolence, Urinary tract infection
SMQs:, Cardiac failure (broad), Angioedema (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-29
   Days after onset: 22
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Eliquis 2.5 mg BID Lasix 40 mg QD KCL 10 meq 3 AM/week gabapentin 300 mg QHS magnesium 120 mg BID Vitamin B12 500 mcg QAM Vitamin B2 100 mg QAM PreserVision AREDS 1 BID Vitamin D3 1000 IU QHS
Current Illness: none
Preexisting Conditions: A-FIB well controlled CHF well controlled TIAs Macular Degeneration
Allergies: Reaction to all medications below is nausea and vomiting codeine bactrim macrobid tramadol
Diagnostic Lab Data: ProBMP metabolic panel urine for C&S CBC
CDC Split Type:

Write-up: profound exhaustion, unable to stay awake even with stimulation, severe anorexia - unwilling to eat pleural effusion +4 leg edema UTI felt like she was shaking internally (found it painful) felt hot (not common) body aches outcome=death

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