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From the 9/17/2021 release of VAERS data:

This is VAERS ID 860135



Case Details

VAERS ID: 860135 (history)  
Form: Version 2.0  
Age: 0.17  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2020-01-29
Onset:2020-02-01
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2020-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR UJ230AA / 1 LL / IM
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS LR537 / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH CG9017 / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1660693 / 1 MO / PO

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Omeprazole 2mg
Current Illness: GERD
Preexisting Conditions: GERD
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 2/1/2020 ED diagnosis- cardiac arrest


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=860135


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