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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1438019

Case Details

VAERS ID: 1438019 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Wisconsin  
   Days after vaccination:120
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data: Coronavirus COVID-19~Coronavirus COVID-19 - 06/29/2021 Coronavirus COVID-19~Coronavirus COVID-19 - 06/30/2021
CDC Split Type:

Write-up: 11/09/2020 - Tested positive for COVID-19 02/08/2021 & 03/01/2021 - Received Pfizer COVID-19 vaccines 06/29/2021 - Tested positive for COVID-19 at Hospital 06/29/2021 - Admitted to Medical Center / Hospital 06/30/2021 - Tested negative for COVID-19 at Medical Center / Hospital 06/30/2021 - Discharged from Medical Center / Hospital

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