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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1761838

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Case Details

VAERS ID: 1761838 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-02-25
Onset:2021-10-04
   Days after vaccination:221
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Private       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? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Alendronate na Aspirin,
Current Illness: HTN, arthritis, hip replacement, hyperlipidemia
Preexisting Conditions: HTN, arthritis, hip replacement, hyperlipidemia
Allergies: NKA
Diagnostic Lab Data: rapid test
CDC Split Type:

Write-up: COVID positive


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1761838


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