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From the 1/7/2022 release of VAERS data:

This is VAERS ID 454855

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Case Details

VAERS ID: 454855 (history)  
Form: Version 1.0  
Age: 0.33  
Sex: Male  
Location: California  
Vaccinated:2012-04-30
Onset:2012-05-01
   Days after vaccination:1
Submitted: 2012-05-02
   Days after onset:1
Entered: 2012-05-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B329AB / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH561AA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F92472 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB214A / 2 MO / PO

Administered by: Unknown       Purchased by: Private
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-05-01
   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: No illness at time of vaccination.
Preexisting Conditions: No pre-existing Physician-Diagnosed Allergies, Birth Defects, or Medical conditions at time of vaccination.
Allergies:
Diagnostic Lab Data: Under investigation
CDC Split Type:

Write-up: Unknown, coroner suspected SIDS.


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