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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 162631 |
VAERS Form: | |
Age: | 0.2 |
Sex: | Male |
Location: | Michigan |
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: INFANRIX / SMITHKLINE | DTAP96042 / 0 | LL / IM |
HIBV: HIBTITER / LEDERLE(PRAXIS) | 473007 / 0 | LL / IM |
IPV: POLIOVAX / CONNAUGHT LTD | R0691 / 0 | RL / IM |
PNC: PREVNAR / LEDERLE | 473337 / 0 | RL / IM |
Administered by: Private Purchased by: Unknown
Symptoms: SIDS
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: INFANRIX DTAP (INFANRIX) / SMITHKLINE SMITHKLINE BEECHAM | DTAP96042 96042 / 0 | LL / IM |
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE LABORATORIES | 473007 / 0 | LL / IM |
IPV: POLIOVAX POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD CONNAUGHT LTD. | R0691 / 0 | RL / IM |
PNC: PREVNAR PNEUMO (PREVNAR) / LEDERLE LEDERLE LABORATORIES | 473337 / 0 | RL / IM |
Administered by: Private Purchased by: Unknown Other
Symptoms: SIDS, Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM | 96042 / 0 | LL / IM |
HIBV: HIB (HIBTITER) / LEDERLE LABORATORIES | 473007 / 0 | LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. | R0691 / 0 | RL / IM |
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / LEDERLE LABORATORIES | 473337 / 0 | RL / IM |
Administered by: Private Purchased by: Other
Symptoms: Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM | 96042 / 0 | LL / IM |
HIBV: HIB (HIBTITER) / LEDERLE LABORATORIES | 473007 / 0 | LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. | R0691 / 0 | RL / IM |
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / LEDERLE LABORATORIES | 473337 / 0 | RL / IM |
Administered by: Private Purchased by: Other
Symptoms: Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM | 96042 / 0 | LL / IM |
HIBV: HIB (HIBTITER) / LEDERLE LABORATORIES PFIZER/WYETH | 473007 / 0 | LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. | R0691 / 0 | RL / IM |
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES PFIZER/WYETH | 473337 / 0 | RL / IM |
Administered by: Private Purchased by: Other
Symptoms: Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM | 96042 / 0 1 | LL / IM |
HIBV: HIB (HIBTITER) / PFIZER/WYETH | 473007 / 0 1 | LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. | R0691 / 0 1 | RL / IM |
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH | 473337 / 0 1 | RL / IM |
Administered by: Private Purchased by: Other
Symptoms: Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM | 96042 / 1 | LL / IM |
HIBV: HIB (HIBTITER) / PFIZER/WYETH | 473007 / 1 | LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. | R0691 / 1 | RL / IM |
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH | 473337 / 1 | RL / IM |
Administered by: Private Purchased by: Other
Symptoms: Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM | 96042 / 1 | LL / IM |
HIBV: HIB (HIBTITER) / PFIZER/WYETH | 473007 / 1 | LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. | R0691 / 1 | RL / IM |
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH | 473337 / 1 | RL / IM |
Administered by: Private Purchased by: Other
Symptoms: Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM | 96042 / 1 | LL / IM |
HIBV: HIB (HIBTITER) / PFIZER/WYETH | 473007 / 1 | LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. | R0691 / 1 | RL / IM |
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH | 473337 / 1 | RL / IM |
Administered by: Private Purchased by: Other
Symptoms: Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM | 96042 / 1 | LL / IM |
HIBV: HIB (HIBTITER) / PFIZER/WYETH | 473007 / 1 | LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. | R0691 / 1 | RL / IM |
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH | 473337 / 1 | RL / IM |
Administered by: Private Purchased by: Other
Symptoms: Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM | 96042 / 1 | LL / IM |
HIBV: HIB (HIBTITER) / PFIZER/WYETH | 473007 / 1 | LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. | R0691 / 1 | RL / IM |
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH | 473337 / 1 | RL / IM |
Administered by: Private Purchased by: Other
Symptoms: Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM | 96042 / 1 | LL / IM |
HIBV: HIB (HIBTITER) / PFIZER/WYETH | 473007 / 1 | LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. | R0691 / 1 | RL / IM |
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH | 473337 / 1 | RL / IM |
Administered by: Private Purchased by: Other
Symptoms: Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Submitted: | 2000-11-20 |
Entered: | 2000-11-28 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM | 96042 / 1 | LL / IM |
HIBV: HIB (HIBTITER) / PFIZER/WYETH | 473007 / 1 | LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. | R0691 / 1 | RL / IM |
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH | 473337 / 1 | RL / IM |
Administered by: Private Purchased by: Other
Symptoms: Sudden infant death syndrome
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2000-11-15
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy - nml
CDC 'Split Type':
Write-up: The pt died from SIDS within 24 hours post vax.
Link To This Search Result:
https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=162631&WAYBACKHISTORY=ON
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