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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1459756

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Case Details

VAERS ID: 1459756 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-04-10
Onset:2021-04-21
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-07-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 UN / IM

Administered by: Other       Purchased by: ?
Symptoms: Autopsy, Death, Histology, Pericarditis, Vasculitis
SMQs:, Systemic lupus erythematosus (broad), Vasculitis (narrow), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-02
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Diabetes
Allergies: Unknown
Diagnostic Lab Data: Autopsy and histology as above
CDC Split Type:

Write-up: Pericarditis, large vessel vasculitis, death


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