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This is VAERS ID 415725

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2011

VAERS ID: 415725
VAERS Form:
Age:0.2
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 0 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 0 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 4/13/2011

VAERS ID: 415725 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 0 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 0 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden death, Sudden infant death syndrome, Autopsy, Toxicologic test normal, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 5/13/2011

VAERS ID: 415725 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 0 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 0 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden death, Sudden infant death syndrome, Autopsy, Toxicologic test normal, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 5/13/2013

VAERS ID: 415725 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 0 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 0 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 2/14/2017

VAERS ID: 415725 Before After
VAERS Form:
Age:0.2 0.18
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 0 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 0 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 9/14/2017

VAERS ID: 415725 Before After
VAERS Form:(blank) 1
Age:0.18
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 0 1 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 1 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 0 1 - MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 2/14/2018

VAERS ID: 415725 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 1 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 6/14/2018

VAERS ID: 415725 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 1 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 8/14/2018

VAERS ID: 415725 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 1 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 9/14/2018

VAERS ID: 415725 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 1 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 10/14/2018

VAERS ID: 415725 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 1 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 12/24/2020

VAERS ID: 415725 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 1 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 12/30/2020

VAERS ID: 415725 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 1 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 5/7/2021

VAERS ID: 415725 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 1 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.


Changed on 5/14/2021

VAERS ID: 415725 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Indiana
Vaccinated:2011-01-13
Onset:2011-01-16
Submitted:2011-01-21
Entered:2011-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3748AB / 1 RL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB833CA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0526Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Death, Respiratory arrest, Sudden infant death syndrome, Autopsy, Toxicologic test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-16
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:
Preexisting Conditions: Clubfoot; tongue-tie
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. received vaccinations at at 10:00am on 1-13-11 - no problems noted after receiving vaccinations. Infant found not breathing at 0930 on 1-16-11 by parents. Had been sleeping in car seat (not strapped in)- in living room. Unable to resuscitate. Pronounced dead at hospital. Autopsy listed cause of death SUIDS - Sudden Unexplained infant death. Awaiting toxicology reports/results.

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