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

This is VAERS ID 1106737

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Case Details

VAERS ID: 1106737 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-03-11
Onset:2021-03-14
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805031 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Death, Malaise
SMQs:, Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   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: melatonin, calcium, vitamin D, famotidine, quetiapine 50 mg QHS
Current Illness: Normal pressure hydrocephalus -- s/p VP shunt with dementia
Preexisting Conditions: BPH, C-spine fracture with myelopathy, GERD
Allergies: opiates, pencillins (hives)
Diagnostic Lab Data: none
CDC Split Type:

Write-up: weakness/malaise per daughter, death on 3/14 (did have underlying medical conditions)


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