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From the 11/12/2021 release of VAERS data:

This is VAERS ID 425873

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Case Details

VAERS ID: 425873 (history)  
Form: Version 1.0  
Age: 0.34  
Sex: Male  
Location: Illinois  
Vaccinated:2011-06-16
Onset:2011-06-20
   Days after vaccination:4
Submitted: 2011-06-22
   Days after onset:2
Entered: 2011-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3911AA / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E70195 / 2 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0530AA / 2 MO / PO

Administered by: Private       Purchased by: Unknown
Symptoms: Gastrointestinal obstruction, Surgery
SMQs:, Gastrointestinal obstruction (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2011-07-08
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 17 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: UGI --$g obstruction
CDC Split Type:

Write-up: Surgical resection.


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