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From the 11/26/2021 release of VAERS data:

This is VAERS ID 63834

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Case Details

VAERS ID: 63834 (history)  
Form: Version 1.0  
Age: 0.4  
Sex: Male  
Location: Maryland  
Vaccinated:1994-06-06
Onset:1994-06-07
   Days after vaccination:1
Submitted: 1994-06-10
   Days after onset:3
Entered: 1994-06-24
   Days after submission:14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4H51058 / 2 LL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1693W / 3 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. J0690 / 2 RL / -

Administered by: Private       Purchased by: Public
Symptoms: Apnoea, Cyanosis
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1994-06-07
   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: Bactrim
Current Illness: NONE
Preexisting Conditions: Degeorge''s synd, congenital interrupted aortic arch;
Allergies:
Diagnostic Lab Data: blood & organ cultures-results pending;
CDC Split Type: MD94018

Write-up: pt had no sx following injects; had acute onset of cyanosis & resp arrest 1 day p/immun; pt had congenital birth defect, Degeorge''s synd w/aortoplasty done 17MAY94;


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