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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1463409



Case Details

VAERS ID: 1463409 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Utah  
Vaccinated:2021-04-15
Onset:2021-07-02
   Days after vaccination:78
Submitted: 0000-00-00
Entered: 2021-07-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8733 / 1 - / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9809 / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Computerised tomogram thorax, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Atorvastatin, Cetirizine, Chlorthalidone, Genvoya, MVI, D3,
Current Illness: Well controlled HIV, HLD, HTN
Preexisting Conditions: Well controlled HIV, HLD, HTN
Allergies: Amoxicillin
Diagnostic Lab Data: CTA Chest 7/10/2021
CDC Split Type:

Write-up: Saddle PE diagnosed 7/10/21


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