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This is VAERS ID 414074

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2011

VAERS ID: 414074
VAERS Form:
Age:0.3
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 1 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 1 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 4/13/2011

VAERS ID: 414074 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 1 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 1 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 5/13/2011

VAERS ID: 414074 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 1 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 1 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 2/14/2017

VAERS ID: 414074 Before After
VAERS Form:
Age:0.3 0.34
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 1 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 1 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 9/14/2017

VAERS ID: 414074 Before After
VAERS Form:(blank) 1
Age:0.34
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 1 2 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 1 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 1 2 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 2/14/2018

VAERS ID: 414074 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 2 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 2 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 6/14/2018

VAERS ID: 414074 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 2 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 2 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 8/14/2018

VAERS ID: 414074 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 2 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 2 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 9/14/2018

VAERS ID: 414074 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 2 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 2 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 10/14/2018

VAERS ID: 414074 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 2 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 2 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 12/24/2020

VAERS ID: 414074 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 2 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 2 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 12/30/2020

VAERS ID: 414074 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 2 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 2 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 5/7/2021

VAERS ID: 414074 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 2 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 2 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 5/14/2021

VAERS ID: 414074 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Colorado
Vaccinated:2010-08-09
Onset:2010-08-10
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3614AA / 2 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBV833DA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E46124 / 2 RL / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-08-10
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:
Current Illness: No
Preexisting Conditions: gastroesophageal reflux treated with ranitidine
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=414074&WAYBACKHISTORY=ON


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