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From the 5/7/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 1230024

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Case Details

VAERS ID: 1230024 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Florida  
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Computerised tomogram thorax abnormal, Death, Dyspnoea, Endotracheal intubation, Hypoxia, Platelet disorder, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Haematopoietic thrombocytopenia (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-04
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: 1. Kidney stones - N20.0 (Primary) 2. Urinary tract infection without hematuria, site unspecified - N39.0 3. Type 2 diabetes mellitus with diabetic chronic kidney disease - E11.22 4. Type 2 diabetes mellitus with other specified complication - E11.69 5. Chronic kidney disease, stage II (mild) - N18.2 6. Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease - I13.0 7. Heart failure, unspecified - I50.9 8. Hyperlipidemia, unspecified - E78.5 9. Atherosclerotic heart disease of native coronary artery without angina pectoris - I25.10 10. Edema, lower extremity - R60.0 11. Chronic obstructive pulmonary disease, unspecified - J44.9 12. Obstructive sleep apnea (adult) (pediatric) - G47.33 13. Peripheral vascular disease, unspecified - I73.9 14. Cardiomyopathy, dilated - I42.0 15. Morbid (severe) obesity due to excess calories - E66.01 16. Nicotine dependence with nicotine-induced disorder - F17.209 17. Bipolar disorder, current episode
Allergies: NKDA
Diagnostic Lab Data: CT of the chest with PE. Nl platelets at arrival. Then decrease
CDC Split Type:

Write-up: Shortness of breath, hypoxia, Pulmonary Embolism, intubation death.

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