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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1771634

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Case Details

VAERS ID: 1771634 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-10-04
Onset:2021-10-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FE3592 / 3 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Extra dose administered, Product preparation issue
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Fosamax 70mg, Lipitor 20mg, Vitamin D3, Vitamin D2, Estriol Micronized, no dosage, Hydrocodone 5-325mg., Liothyronine no dosage needed, progesterone 200mg, tofacitinib 11mg.
Current Illness: None
Preexisting Conditions: None
Allergies: Morphine
Diagnostic Lab Data: none
CDC Split Type:

Write-up: An entire .3ml bottle of Covid vaccine was drawn and put in the 2ml sodium chloride diluent. A .3ml covid dose was drawn and administered to the patient. This was the patients 3rd dose


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