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

This is VAERS ID 178757

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Case Details

VAERS ID: 178757 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: North Carolina  
Vaccinated:2001-11-28
Onset:2001-11-29
   Days after vaccination:1
Submitted: 2001-11-29
   Days after onset:0
Entered: 2001-12-10
   Days after submission:11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR UO536CA / 1 LL / -
HBPV: HIB POLYSACCHARIDE (HIBIMUNE) / PFIZER/WYETH 480935 / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T1031 / 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480395 / 1 RL / -

Administered by: Private       Purchased by: Public
Symptoms: Cardiac arrest, Sudden infant death syndrome
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), Neonatal disorders (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2001-11-29
   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: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Post mortem exam
CDC Split Type:

Write-up: Pt found asystolic at approximately 2 AM in his crib on 11/29/2001. COD as per autopsy report --SIDS/sr


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