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

This is VAERS ID 64863

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Case Details

VAERS ID: 64863 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Texas  
Vaccinated:1994-06-27
Onset:1994-06-27
   Days after vaccination:0
Submitted: 1994-07-05
   Days after onset:8
Entered: 1994-07-22
   Days after submission:17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010KD / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 1 LL / SC

Administered by: Private       Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor
SMQs:, Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 1994-06-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


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