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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1428157

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Case Details

VAERS ID: 1428157 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Foreign  
Vaccinated:0000-00-00
Onset:2021-05-17
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Akathisia, Increased bronchial secretion, Pyrexia, Restlessness
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Akathisia (narrow), Noninfectious encephalopathy/delirium (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PITAVASTATINA CINFA; URSOBILANE; EDOXABAN
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: ESJNJFOC20210641756

Write-up: MOTOR RESTLESSNESS; INNER RESTLESSNESS; RAFT PRODUCTION; FEVER; This spontaneous report received from a consumer via a Regulatory Authority [ ES-AEMPS-902043] concerned a 62-year-old male. The patient''s weight, height, and medical history were not reported. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin, and batch number were not reported) dose was not reported, frequency 1 total, administered on 17-MAY-2021 for covid-19 vaccination. The batch number was not reported. Per procedure, no follow-up will be requested for this case. Concomitant medications included pitavastatin 25 mg, ursodeoxycholic acid 300 mg, and edoxaban used for unknown indication. On 17-MAY-2021, the patient experienced raft production and fever. On 18-MAY-2021, he experienced inner restlessness. On 20-MAY-2021, the patient experienced motor restlessness. On an unspecified date, the patient died. It was unknown if autopsy was performed. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient died of inner restlessness, raft production, motor restlessness and fever on an unspecified date. This report was serious (Death).; Sender''s Comments: V0:20210641756-covid-19 vaccine ad26.cov2.s-raft production,fever,inner restlessness,motor restlessness. This event(s) is considered unassessable. The event(s) has a compatible/suggestive temporal relationship, is unlabeled, and has unknown scientific plausibility. There is no information on any other factors potentially associated with the event(s).; Reported Cause(s) of Death: INNER RESTLESSNESS; RAFT PRODUCTION; MOTOR RESTLESSNESS; FEVER


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