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From the 11/26/2021 release of VAERS data:

This is VAERS ID 421094

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Case Details

VAERS ID: 421094 (history)  
Form: Version 1.0  
Age: 0.19  
Sex: Female  
Location: New Hampshire  
Vaccinated:2011-02-01
Onset:2011-03-03
   Days after vaccination:30
Submitted: 2011-03-03
   Days after onset:0
Entered: 2011-04-15
   Days after submission:42
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3613AA / 1 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB977AA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0948Z / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-03-03
   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: Acyclovir at birth 25 mg IV Q 6 Hrs.
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: NH04151101

Write-up: Mother had + HSV, gestational diabetes and protein S deficiency.


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