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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1467709

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Case Details

VAERS ID: 1467709 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-07-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Chest pain, Death
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-04
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Abdominal aneurysm; Hypertonus; Neurodermatitis
Preexisting Conditions: Comments: Unknown
Allergies:
Diagnostic Lab Data:
CDC Split Type: DEJNJFOC20210721703

Write-up: DIED UNKNOWN; THORACIC PAIN; This spontaneous report received from a consumer via a Regulatory Authority [ DE-PEI-CADR2021124321] concerned a 69 year old male of unknown race and ethnicity. The patient''s height, and weight were not reported. The patient''s concurrent conditions included neurodermatitis, abdominal aneurysm, and hypertonus. 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, 1 total administered on 04-JUN-2021 for prophylactic vaccination. The batch number was not reported. Per procedure, no follow-up will be requested for this case. No concomitant medications were reported. On an unspecified date, the patient experienced thoracic pain. On 04-JUN-2021, the patient died from unknown cause of death. An autopsy was not performed. The action taken with covid-19 vaccine was not applicable. The patient died of died unknown on 04-JUN-2021, and had not recovered from thoracic pain. This report was serious (Death).; Sender''s Comments: V0:20210721703-COVID-19 VACCINE Death. This event(s) is considered unassessable. The event(s) has an unknown/unclear 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: UNKNOWN CAUSE OF DEATH


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