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This is VAERS ID 30143

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 30143
VAERS Form:
Age:0.3
Sex:Male
Location:Tennessee
Vaccinated:1991-02-27
Onset:1991-03-03
Submitted:1991-03-08
Entered:1991-05-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: TRI-IMMUNOL / LEDERLE 289963 / 0 LL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) M640FN / 0 RL / IM
OPV: ORIMUNE / LEDERLE 291947 / 0 - / PO

Administered by: Public      Purchased by: Unknown
Symptoms: SIDS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-03-03
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: NONE
Other Medications:
Current Illness: Infant had an ear infect 2 wks prior vax
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': NONE

Write-up: Autopsy performed, cause of death determined to be sudden infant death synd;


Changed on 12/8/2009

VAERS ID: 30143 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Tennessee
Vaccinated:1991-02-27
Onset:1991-03-03
Submitted:1991-03-08
Entered:1991-05-02 1991-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: TRI-IMMUNOL DTP (TRI-IMMUNOL) / LEDERLE LEDERLE LABORATORIES 289963 / 0 LL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS M640FN / 0 RL / IM
OPV: ORIMUNE POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LEDERLE LABORATORIES 291947 / 0 - / PO

Administered by: Public      Purchased by: Unknown
Symptoms: SIDS, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-03-03
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: NONE
Other Medications:
Current Illness: Infant had an ear infect 2 wks prior vax
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': NONE TN9153

Write-up: Autopsy performed, cause of death determined to be sudden infant death synd;


Changed on 5/14/2017

VAERS ID: 30143 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Tennessee
Vaccinated:1991-02-27
Onset:1991-03-03
Submitted:1991-03-08
Entered:1991-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 289963 / 0 LL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH M640FN / 0 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 291947 / 0 - / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-03-03
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: NONE NONE~ ()~~~In patient
Other Medications:
Current Illness: Infant had an ear infect 2 wks prior vax
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN9153

Write-up: Autopsy performed, cause of death determined to be sudden infant death synd;


Changed on 9/14/2017

VAERS ID: 30143 Before After
VAERS Form:(blank) 1
Age:0.3
Sex:Male
Location:Tennessee
Vaccinated:1991-02-27
Onset:1991-03-03
Submitted:1991-03-08
Entered:1991-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 289963 / 0 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M640FN / 0 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 291947 / 0 1 - MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-03-03
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: NONE~ ()~~~In patient
Other Medications:
Current Illness: Infant had an ear infect 2 wks prior vax
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN9153

Write-up: Autopsy performed, cause of death determined to be sudden infant death synd;


Changed on 2/14/2018

VAERS ID: 30143 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Tennessee
Vaccinated:1991-02-27
Onset:1991-03-03
Submitted:1991-03-08
Entered:1991-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 289963 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M640FN / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 291947 / 1 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-03-03
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: NONE~ ()~~~In patient
Other Medications:
Current Illness: Infant had an ear infect 2 wks prior vax
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN9153

Write-up: Autopsy performed, cause of death determined to be sudden infant death synd;


Changed on 6/14/2018

VAERS ID: 30143 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Tennessee
Vaccinated:1991-02-27
Onset:1991-03-03
Submitted:1991-03-08
Entered:1991-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 289963 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M640FN / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 291947 / 1 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-03-03
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: NONE~ ()~~~In patient
Other Medications:
Current Illness: Infant had an ear infect 2 wks prior vax
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN9153

Write-up: Autopsy performed, cause of death determined to be sudden infant death synd;


Changed on 8/14/2018

VAERS ID: 30143 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Tennessee
Vaccinated:1991-02-27
Onset:1991-03-03
Submitted:1991-03-08
Entered:1991-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 289963 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M640FN / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 291947 / 1 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-03-03
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: NONE~ ()~~~In patient
Other Medications:
Current Illness: Infant had an ear infect 2 wks prior vax
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN9153

Write-up: Autopsy performed, cause of death determined to be sudden infant death synd;


Changed on 9/14/2018

VAERS ID: 30143 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Tennessee
Vaccinated:1991-02-27
Onset:1991-03-03
Submitted:1991-03-08
Entered:1991-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 289963 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M640FN / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 291947 / 1 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-03-03
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: NONE~ ()~~~In patient
Other Medications:
Current Illness: Infant had an ear infect 2 wks prior vax
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN9153

Write-up: Autopsy performed, cause of death determined to be sudden infant death synd;


Changed on 10/14/2018

VAERS ID: 30143 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Tennessee
Vaccinated:1991-02-27
Onset:1991-03-03
Submitted:1991-03-08
Entered:1991-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 289963 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M640FN / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 291947 / 1 MO / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-03-03
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: NONE~ ()~~~In patient
Other Medications:
Current Illness: Infant had an ear infect 2 wks prior vax
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': TN9153

Write-up: Autopsy performed, cause of death determined to be sudden infant death synd;

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