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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1500766



Case Details

VAERS ID: 1500766 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-03-18
Onset:2021-03-22
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-07-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN602 / 1 UN / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN607 / 2 UN / IM

Administered by: School       Purchased by: ?
Symptoms: Amnesia, Balance disorder, Brain operation, Death, Thrombosis
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-30
   Days after onset: 69
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Gabapentin, mylaxocam, tylenol
Current Illness: None
Preexisting Conditions: Carpal tunnel left wrist, Arthritis right shoulder, Gi problems ie kidney stones.
Allergies: Unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Loss of balance, loss of memory, blood clots, hospitalization, brain surgery, death


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1500766

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