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

This is VAERS ID 1782430

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Case Details

VAERS ID: 1782430 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Wisconsin  
   Days after vaccination:217
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 2 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / -

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, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: alendronate, aspirin, atorvastatin, calcium carbonate/vitamin, furosemide, metoprolol succinate, mirtazapine
Current Illness:
Preexisting Conditions:
Allergies: Cefazolin, Fish Derived, Ondansetron Hcl, Ibuprofen
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient admitted as inpatient on 10/10/21 due to Pneumonia due to COVID-19 virus. Patient was tested for COVID-19 and was positive on 10/9/21.

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