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This is VAERS ID 113721

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 113721
VAERS Form:
Age:0.3
Sex:Male
Location:New Jersey
Vaccinated:1998-08-14
Onset:1998-08-23
Submitted:1998-08-26
Entered:1998-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: TRIPEDIA / CONNAUGHT LABS 934790 / 1 RL / IM
HIBV: ACT-HIB / CONNAUGHT LABS 2699H2 / 1 LL / IM
IPV: POLIOVAX / CONNAUGHT LTD N0492 / 1 LL / IM

Administered by: Private      Purchased by: Unknown
Symptoms: SLEEP POSITION

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-08-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: gross autopsy reported to have shown no identifiable cause of death;pathology/tissue report pending;
CDC 'Split Type':

Write-up: pt found lifeless in bed;head reported to have been wedged between mattress & wall;


Changed on 12/8/2009

VAERS ID: 113721 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:New Jersey
Vaccinated:1998-08-14
Onset:1998-08-23
Submitted:1998-08-26
Entered:1998-09-01 1998-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: TRIPEDIA DTAP (TRIPEDIA) / CONNAUGHT LABS CONNAUGHT LABORATORIES 934790 / 1 RL / IM
HIBV: ACT-HIB HIB (ACTHIB) / CONNAUGHT LABS CONNAUGHT LABORATORIES 2699H2 / 1 LL / IM
IPV: POLIOVAX POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD CONNAUGHT LTD. N0492 / 1 LL / IM

Administered by: Private      Purchased by: Unknown Private
Symptoms: Unevaluable event, SLEEP POSITION

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-08-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: gross autopsy reported to have shown no identifiable cause of death;pathology/tissue report pending;
CDC 'Split Type':

Write-up: pt found lifeless in bed;head reported to have been wedged between mattress & wall;


Changed on 5/14/2017

VAERS ID: 113721 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:New Jersey
Vaccinated:1998-08-14
Onset:1998-08-23
Submitted:1998-08-26
Entered:1998-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 934790 / 1 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 2699H2 / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0492 / 1 LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-08-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: gross autopsy reported to have shown no identifiable cause of death;pathology/tissue report pending;
CDC 'Split Type':

Write-up: pt found lifeless in bed;head reported to have been wedged between mattress & wall;


Changed on 9/14/2017

VAERS ID: 113721 Before After
VAERS Form:(blank) 1
Age:0.3
Sex:Male
Location:New Jersey
Vaccinated:1998-08-14
Onset:1998-08-23
Submitted:1998-08-26
Entered:1998-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 934790 / 1 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 2699H2 / 1 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0492 / 1 2 LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-08-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: gross autopsy reported to have shown no identifiable cause of death;pathology/tissue report pending;
CDC 'Split Type':

Write-up: pt found lifeless in bed;head reported to have been wedged between mattress & wall;


Changed on 2/14/2018

VAERS ID: 113721 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New Jersey
Vaccinated:1998-08-14
Onset:1998-08-23
Submitted:1998-08-26
Entered:1998-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 934790 / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 2699H2 / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0492 / 2 LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-08-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: gross autopsy reported to have shown no identifiable cause of death;pathology/tissue report pending;
CDC 'Split Type':

Write-up: pt found lifeless in bed;head reported to have been wedged between mattress & wall;


Changed on 6/14/2018

VAERS ID: 113721 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New Jersey
Vaccinated:1998-08-14
Onset:1998-08-23
Submitted:1998-08-26
Entered:1998-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 934790 / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 2699H2 / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0492 / 2 LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-08-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: gross autopsy reported to have shown no identifiable cause of death;pathology/tissue report pending;
CDC 'Split Type':

Write-up: pt found lifeless in bed;head reported to have been wedged between mattress & wall;


Changed on 8/14/2018

VAERS ID: 113721 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New Jersey
Vaccinated:1998-08-14
Onset:1998-08-23
Submitted:1998-08-26
Entered:1998-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 934790 / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 2699H2 / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0492 / 2 LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-08-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: gross autopsy reported to have shown no identifiable cause of death;pathology/tissue report pending;
CDC 'Split Type':

Write-up: pt found lifeless in bed;head reported to have been wedged between mattress & wall;


Changed on 9/14/2018

VAERS ID: 113721 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New Jersey
Vaccinated:1998-08-14
Onset:1998-08-23
Submitted:1998-08-26
Entered:1998-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 934790 / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 2699H2 / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0492 / 2 LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-08-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: gross autopsy reported to have shown no identifiable cause of death;pathology/tissue report pending;
CDC 'Split Type':

Write-up: pt found lifeless in bed;head reported to have been wedged between mattress & wall;


Changed on 10/14/2018

VAERS ID: 113721 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New Jersey
Vaccinated:1998-08-14
Onset:1998-08-23
Submitted:1998-08-26
Entered:1998-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 934790 / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 2699H2 / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0492 / 2 LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-08-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: gross autopsy reported to have shown no identifiable cause of death;pathology/tissue report pending;
CDC 'Split Type':

Write-up: pt found lifeless in bed;head reported to have been wedged between mattress & wall;

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=113721&WAYBACKHISTORY=ON


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