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

This is VAERS ID 1426477

Case Details

VAERS ID: 1426477 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Indiana  
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute respiratory failure, Atrial fibrillation, COVID-19 pneumonia, Condition aggravated, Death, Hypertension, Nucleic acid test, Obesity, Polymerase chain reaction, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), 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), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Hypertension (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-15
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID 19 pneumonia
Preexisting Conditions: Paroxysmal atrial fibrillation obesity hypertension
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 5/15/2021 Causes of death listed on death certificate: 1) COVID 19 pneumonia 2) Acute respiratory failure with hypoxia 3) Pulmonary embolism 4) Paroxysmal atrial fibrillation Other: obesity, hypertension

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