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

This is VAERS ID 269004

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Case Details

VAERS ID: 269004 (history)  
Form: Version 1.0  
Age: 0.19  
Sex: Male  
Location: Virginia  
Vaccinated:2006-12-04
Onset:2006-12-09
   Days after vaccination:5
Submitted: 2006-12-13
   Days after onset:4
Entered: 2006-12-18
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2627AA / 1 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08649A / 1 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0389F / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms:
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2006-12-09
   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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received Daptacel, Prevnar and Rotateq on 12/04/2006. Also his twin brother received at the same time. Did not have any SX. On 12/09/06 mom fed them at 5am and found them dead at 9:00 am. 6/29/07 Received Autopsy Report which reveals COD as Undetermined & contributing condition simultaneous death of twin brother. Pathological Dx: I. Sudden unexpected infant death A. Twin B infant male found unresponsive in crib on stomach B. Vitreous electrolytes, abnormal, w/decreased Na & increased Cl, urea nitrogen, calcium, carbon dioxide C. Brain congestion & edema, neuronal heterotopia & insular micro-dysgenesis, mild focal. II. Ancillary studies, other, non-contributory. III. Simultaneous death of twin brother IV. Fractures, ribs, anterior & lateral, w/minimal hemorrhage.


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