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

This is VAERS ID 1365365



Case Details

VAERS ID: 1365365 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-05-25
Onset:2021-05-29
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-06-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805018 / UNK RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: multivitamin, Cytomel, Lasix, Keppra, Advair, Clozaril, Norvasc, amiodarone, potassium chloride, senna plus, buspirone, melatonin, Aldactone, Zyprexa, Lexapro, Cogentin
Current Illness:
Preexisting Conditions: COPD, A-Fib, CKD, Hepatitis C, HTN, hyponatremia, EPS, Insomnia, edema, nicotine dependence, BPH, hypothyroidism, iron deficiency anemia, osteoarthritis
Allergies: penicillin
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident received Janssen Covid 19 vaccination on 5/25. On 5/29, the resident died.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1365365

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