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This is VAERS ID 417137

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2011

VAERS ID: 417137
VAERS Form:
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:0000-00-00
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 1 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 0 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NORINYL
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.


Changed on 4/13/2011

VAERS ID: 417137 Before After
VAERS Form:
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:0000-00-00 2011-02-02
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 1 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 0 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NORINYL
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.


Changed on 8/12/2011

VAERS ID: 417137 Before After
VAERS Form:
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:2011-02-02
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 1 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 0 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Blood culture positive, CSF culture positive, Culture throat positive, Death, Dehydration, Diarrhoea, Disseminated intravascular coagulation, Nausea, Obesity, Pleural effusion, Pulmonary haemorrhage, Toxic shock syndrome, Excoriation, Streptococcal bacteraemia, Oropharyngeal pain, Streptococcus test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NORINYL
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.


Changed on 6/14/2014

VAERS ID: 417137 Before After
VAERS Form:
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:2011-02-02
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 1 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 0 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Blood culture positive, CSF culture positive, Culture throat positive, Death, Dehydration, Diarrhoea, Disseminated intravascular coagulation, Nausea, Obesity, Pleural effusion, Pulmonary haemorrhage, Toxic shock syndrome, Excoriation, Streptococcal bacteraemia, Oropharyngeal pain, Streptococcus test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NORINYL
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.


Changed on 3/14/2015

VAERS ID: 417137 Before After
VAERS Form:
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:2011-02-02
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 1 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 0 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Blood culture positive, CSF culture positive, Culture throat positive, Death, Dehydration, Diarrhoea, Disseminated intravascular coagulation, Nausea, Obesity, Pleural effusion, Pulmonary haemorrhage, Toxic shock syndrome, Excoriation, Streptococcal bacteraemia, Oropharyngeal pain, Streptococcus test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.


Changed on 4/14/2017

VAERS ID: 417137 Before After
VAERS Form:
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:2011-02-02
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 1 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 0 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NORINYL
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.


Changed on 9/14/2017

VAERS ID: 417137 Before After
VAERS Form:(blank) 1
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:2011-02-02
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 1 2 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 0 1 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NORINYL
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.


Changed on 2/14/2018

VAERS ID: 417137 Before After
VAERS Form:1
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:2011-02-02
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 2 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 1 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NORINYL
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.


Changed on 6/14/2018

VAERS ID: 417137 Before After
VAERS Form:1
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:2011-02-02
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 2 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 1 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NORINYL
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.


Changed on 8/14/2018

VAERS ID: 417137 Before After
VAERS Form:1
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:2011-02-02
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 2 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 1 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NORINYL
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.


Changed on 9/14/2018

VAERS ID: 417137 Before After
VAERS Form:1
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:2011-02-02
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 2 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 1 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NORINYL
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.


Changed on 10/14/2018

VAERS ID: 417137 Before After
VAERS Form:1
Age:17.0
Gender:Female
Location:Tennessee
Vaccinated:2011-01-04
Onset:2011-02-02
Submitted:2011-02-08
Entered:2011-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0096Z / 2 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U3432AA / 1 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NORINYL
Current Illness: none
Preexisting Conditions: Hay fever; Animal fur
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN1101

Write-up: Patient deceased within 30 days of vaccine administration.

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