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From the 7/16/2021 release of VAERS data:

This is VAERS ID 1255787



Case Details

VAERS ID: 1255787 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Male  
Location: Foreign  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN UNKNOWN / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Death, Thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: The patient was very healthy
Allergies:
Diagnostic Lab Data:
CDC Split Type: VNJNJFOC20210435630

Write-up: DEATH; BLOOD COAGULATION; This spontaneous report received from a consumer concerned a 21 year old male. The patient''s weight, height, and medical history were not reported. It was noted the patient was very healthy. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported, batch number: UNKNOWN, Expiry :UNKNOWN) dose, start therapy date were not reported 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 in 2021, the patient developed blood coagulation, reported as "the vaccine caused blood coagulation". The patient subsequently died 10 days after vaccination; the cause of death was not provided. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The outcome for the event blood coagulation was not provided. The patient died on an unspecified date 10 days after vaccination. This report was serious (Death and Other Medically Important Condition).; Sender''s Comments: V0: This 21-year-old male patient was reported in social media to have developed "blood coagulation" after an unspecified duration of receiving COVID-19 VACCINE AD26.COV2.S. The patient died from an unspecified cause 10 days after vaccination. No other details was reported. Based on the information that is available, the event is assessed as indeterminate with the causal association to immunization, per WHO causality classification of adverse events following immunization based on a lack of a definitive plausible biological mechanism. However, considering the temporal relationship and recently evolving theories in the literature about COVID infections and vaccinations, potential vaccine contribution cannot be excluded. Additional information will be requested for further assessment once contact information is available.; Reported Cause(s) of Death: DEATH


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