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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1120842

Case Details

VAERS ID: 1120842 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Alabama  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Abnormal behaviour, Brain operation, Death, Endotracheal intubation, Lung disorder, Mechanical ventilation, Renal disorder, Seizure, Thrombosis
SMQs:, Angioedema (broad), Systemic lupus erythematosus (broad), Dementia (broad), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 42
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none known of
Preexisting Conditions: type 2 diabetes, other unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: this is all per family, 4 to 5 days after 2nd COVID vaccine he was acting unusual and was taken to the hospital. He had a clot in his brain and underwent brain surgery. He experienced seizures after the surgery, but it was ultimately reported the surgery went well. He remained intubated and on a ventilator after surgery. He developed complications of his lungs and kidneys while on the ventilator. Ventilator was removed 3/16/2021 and he passed away that day. The hospital providers thought the clot in the brain may have been from hitting his head over a month ago. From my understanding he was A&O, independent with ADLs, and lived in his private residence prior to these complications.

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