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From the 6/11/2021 release of VAERS data:

This is VAERS ID 404258



Case Details

VAERS ID: 404258 (history)  
Form: Version 1.0  
Age: 1.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2010-10-11
Onset:2010-10-18
   Days after vaccination:7
Submitted: 2010-10-18
   Days after onset:0
Entered: 2010-10-19
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / UNK RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / UNK LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / UNK LL / IM

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2010-10-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, or
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=404258


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