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

This is VAERS ID 262780

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Case Details

VAERS ID: 262780 (history)  
Form: Version 1.0  
Age: 0.17  
Sex: Male  
Location: Kansas  
Vaccinated:2006-09-06
Onset:2006-09-08
   Days after vaccination:2
Submitted: 2006-09-09
   Days after onset:1
Entered: 2006-09-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2649AA / 1 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 0237F / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Y1031 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08683E / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0578F / 1 MO / PO

Administered by: Unknown       Purchased by: Unknown
Symptoms: Apnoea
SMQs:, Acute central respiratory depression (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2006-09-08
   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: Infant multivitamin liquid with iron
Current Illness: None
Preexisting Conditions: Prematurity- 32 weeks gestation Twin B Breech vaginal delivery Apnea of prematurity Anemia of prematurity
Allergies:
Diagnostic Lab Data: CBC performed on 08/30/2006 prior to vaccination showed WBC 8.83, Hgb 9.1, Hct 25.4, platelets 321K. Glucose during
CDC Split Type:

Write-up: Child was found apneic in his crib. EMS was contacted. Mother performed CPR. Child was pulseless when EMS arrived. Upon arrival to local hospital, child was asystolic with no response to chemical resuscitation.


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