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

This is VAERS ID 1474629



Case Details

VAERS ID: 1474629 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: D.C.  
Vaccinated:1961-01-08
Onset:2021-07-15
   Days after vaccination:22103
Submitted: 0000-00-00
Entered: 2021-07-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0178 / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Inappropriate schedule of product administration
SMQs:, Medication errors (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? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: No
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: 2nd dose vaccine given after 42 days


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