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From the 6/14/2018 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 288471



Case Details

VAERS ID: 288471 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: California  
Vaccinated:2007-08-16
Onset:2007-08-17
   Days after vaccination:1
Submitted: 2007-08-20
   Days after onset:3
Entered: 2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 1 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Respiratory arrest, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2007-08-17
   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: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC Split Type:

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20180614&IDNUMBER=288471

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