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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1391767



Case Details

VAERS ID: 1391767 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-03-22
Onset:2021-06-04
   Days after vaccination:74
Submitted: 0000-00-00
Entered: 2021-06-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6199 / 1 UN / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8730 / 2 UN / IM

Administered by: Public       Purchased by: ?
Symptoms: Dyspnoea, Laboratory test abnormal
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Congestive heart failure, asthma HX of stroke
Allergies: Unknown
Diagnostic Lab Data: Antigen testing on 06/06/2021, came back positive PCR testing on 06/06/2021, came back positive
CDC Split Type:

Write-up: Patient became symptomatic with shortness of breath on 06/04/2021. She was admitted into the hospital on 06/06/2021. She was discharged on 06/08/2021.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1391767


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