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From the 1/14/2022 release of VAERS data:

This is VAERS ID 453867

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Case Details

VAERS ID: 453867 (history)  
Form: Version 1.0  
Age: 0.43  
Sex: Male  
Location: New Hampshire  
Vaccinated:2012-04-04
Onset:2012-04-14
   Days after vaccination:10
Submitted: 2012-04-17
   Days after onset:3
Entered: 2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 2 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 2 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-04-14
   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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC Split Type: NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


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