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

This is VAERS ID 1481541

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Case Details

VAERS ID: 1481541 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-05-26
Onset:2021-05-30
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-07-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 207A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Cardiac arrest, Myocarditis, Sudden cardiac death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lomotil Immodium
Current Illness: None. Had actually seen by her gyn-onc and colon surgery physicians and her stoma wound care nurse in the 3 days prior to her sudden death, and was given a clean bill of health.
Preexisting Conditions: Endometrial adenocarcinoma 5/2020 treated with definitive radiation therapy, palliative surgery, developed a colovaginal fistula and needed an ileostomy in 12/2020. She had a saddle pulmonary embolus in 6/2020.
Allergies: None
Diagnostic Lab Data: Autopsy noted myocarditis as the most significant anatomic finding.
CDC Split Type:

Write-up: Sudden cardiac arrest 5/30/21 (4 days after vaccination)


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