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

This is VAERS ID 1457614

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Case Details

VAERS ID: 1457614 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-06-15
Onset:2021-06-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 205A21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abnormal behaviour, Death, Exophthalmos, Motor dysfunction
SMQs:, Peripheral neuropathy (broad), Dementia (broad), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Hyperthyroidism (narrow), Ocular infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-07-04
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: states flu vaccine gave him the flu (unknown date of specific vaccine)
Other Medications: Patient wife not good historian. According to other pharmacy where patient filled, he has been on isosorbide, citalopram, quetiapine, risperidone, rosuvastatin, and tamsulosin in past. Patient was nonadherent according to that pharmacist. P
Current Illness: N/A
Preexisting Conditions: Vascular dementia with behaviors, coronary artery disease, hyperlipidemia, history of left hip pain, history of bladder stones, heurogenic bladder, history of coronary artery bypass graft x5
Allergies: Aricept, oxybutinin, terbinafine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient''s wife states that he was not the same the evening after receiving the vaccine. She stated that he was unable to hold objects and his eyes were bulging from his head. He was going to a nursing facility after vaccination and later died on 7/4/21.


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