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From the 5/7/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 1104430



Case Details

VAERS ID: 1104430 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-12
Onset:2021-03-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802070 / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient has been admitted to a home hospice program since approximately 11/12/20 with an initial terminal diagnosis of dysphagia which was later changed in February 2021 to vascular dementia. Patient with significant past medical history of several CVA''s which led to aphasia and vascular dementia.


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1104430

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