Sam Baker, Philadelphia vs. San Francisco, December 21, 1969.
Wide from 46 yards near the end of the first half.
(Baker’s day also included an aborted extra point and two other missed field goals, including a potential game-winning 19-yarder with 59 seconds left. It turned out to be the last game of his NFL career, as the Eagles cut him the following preseason.)
The full list of known fair catch kicks can be found here.
Thanks to Tom Gower for the tip.