This is VAERS ID 113721

(NOTE: This result is from the 5/14/2017 version of the VAERS database)

Case Details

VAERS ID:	113721 (history)
Form:	Version .0
Age:	0.3
Sex:	Male
Location:	New Jersey

Vaccinated:	1998-08-14
Onset:	1998-08-23
Days after vaccination:	9
Submitted:	1998-08-26
Days after onset:	3
Entered:	1998-08-31
Days after submission:	5

Vaccination / Manufacturer	Lot / Dose	Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES	934790 / 1	RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES	2699H2 / 1	LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD.	N0492 / 1	LL / IM

Administered by: Private Purchased by: Private
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1998-08-23
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: gross autopsy reported to have shown no identifiable cause of death;pathology/tissue report pending;
CDC Split Type:

Write-up: pt found lifeless in bed;head reported to have been wedged between mattress & wall;

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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20170514&IDNUMBER=113721