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From the 12/31/2003 release of VAERS data (an older release, current is 1/7/2022):

This is VAERS ID 80084

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Case Details

VAERS ID: 80084 (history)  
Form: Version .0  
Age: 31.0  
Sex: Female  
Location: California  
Vaccinated:1995-12-01
Onset:1995-12-01
   Days after vaccination:0
Submitted: 1995-12-12
   Days after onset:11
Entered: 1995-12-20
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
CHOL: CHOLERA VACCINE USP / WYETH 4948171 / - RA / -
HEPA: HAVRIX / SMITHKLINE ZHA467AC / - LA / -

Administered by: Private       Purchased by: Unknown
Symptoms: AMNESIA, CONVULS, HYPERTONIA, HYPOTENS, PALLOR
SMQs:

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: n/a
Other Medications: none
Current Illness: none
Preexisting Conditions: pcn allergy;
Allergies:
Diagnostic Lab Data: none
CDC Split Type: pcn allergy;

Write-up: pt recvd vax; leaned forward 180 pulse; turned pale, convulsive state;became rigis & passed out;pt came to no memory of incident;felt fine;90/70 pulse 84;


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