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

This is VAERS ID 1478347

Case Details

VAERS ID: 1478347 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Michigan  
   Days after vaccination:120
Submitted: 0000-00-00
Entered: 2021-07-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

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

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, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Beta-carotene, lexapro, cozaar, lopressor, crestor, chemotherapy
Current Illness: Adenocarcinoma of right lung
Preexisting Conditions: history of Hodgkins lymphoma, adenocarcinoma of right lung, bronchiectasis, severe aortic stenosis, HTN, hyperlipidemia, CKD stage 3, depression, immunosuppressed from chemotherapy
Allergies: NKA
Diagnostic Lab Data: Positive COVID PCR on 07/01/21 and 01/13/2021.
CDC Split Type:

Write-up: Fully vaccinated patient with additional history of COVID infection in January positive for COVID and admitted for COVID PNA.

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