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

This is VAERS ID 121007

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Case Details

VAERS ID: 121007 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: Michigan  
Vaccinated:1999-03-30
Onset:1999-04-01
   Days after vaccination:2
Submitted: 1999-04-06
   Days after onset:4
Entered: 1999-04-07
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 RL / -

Administered by: Private       Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Neonatal disorders (narrow), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1999-04-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


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