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This is VAERS ID 30667

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 30667
VAERS Form:
Age:0.3
Sex:Male
Location:New York
Vaccinated:1991-05-03
Onset:1991-05-07
Submitted:1991-05-14
Entered:1991-05-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP / CONNAUGHT LABS 0C21045 / 1 LL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) M130HA / 1 RL / IM
OPV: ORIMUNE / LEDERLE 295957 / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: SIDS, APNEA, HEART ARREST

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-07
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: pt was finishing course of Ceclor
Current Illness: resolving otitis media
Preexisting Conditions: rt hydrocele
Allergies:
Diagnostic Lab Data: Autopsy done 7May91.Provisional Anatomic Diagnoses:Consistent /w SIDS
CDC 'Split Type': rt hydrocele

Write-up: Pt recvd immun on 3May91,@time of 4mo well baby checkup.Pt was seen in ER on 7May91 @ 630am in cardiac & respiratory arrest as an apparent SIDS death & pronounced dead /p CPR attempts.


Changed on 12/8/2009

VAERS ID: 30667 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:New York
Vaccinated:1991-05-03
Onset:1991-05-07
Submitted:1991-05-14
Entered:1991-05-23 1991-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP DTP (NO BRAND NAME) / CONNAUGHT LABS CONNAUGHT LABORATORIES 0C21045 / 1 LL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS M130HA / 1 RL / IM
OPV: ORIMUNE POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LEDERLE LABORATORIES 295957 / 1 - / PO

Administered by: Private      Purchased by: Unknown Private
Symptoms: Apnoea, Cardiac arrest, SIDS, Sudden infant death syndrome, APNEA, HEART ARREST

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-07
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: pt was finishing course of Ceclor
Current Illness: resolving otitis media
Preexisting Conditions: rt hydrocele
Allergies:
Diagnostic Lab Data: Autopsy done 7May91.Provisional Anatomic Diagnoses:Consistent /w SIDS
CDC 'Split Type': rt hydrocele (blank)

Write-up: Pt recvd immun on 3May91,@time of 4mo well baby checkup.Pt was seen in ER on 7May91 @ 630am in cardiac & respiratory arrest as an apparent SIDS death & pronounced dead /p CPR attempts.


Changed on 5/14/2017

VAERS ID: 30667 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:New York
Vaccinated:1991-05-03
Onset:1991-05-07
Submitted:1991-05-14
Entered:1991-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21045 / 1 LL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH M130HA / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 295957 / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-07
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: pt was finishing course of Ceclor
Current Illness: resolving otitis media
Preexisting Conditions: rt hydrocele
Allergies:
Diagnostic Lab Data: Autopsy done 7May91.Provisional Anatomic Diagnoses:Consistent /w SIDS
CDC 'Split Type':

Write-up: Pt recvd immun on 3May91,@time of 4mo well baby checkup.Pt was seen in ER on 7May91 @ 630am in cardiac & respiratory arrest as an apparent SIDS death & pronounced dead /p CPR attempts.


Changed on 9/14/2017

VAERS ID: 30667 Before After
VAERS Form:(blank) 1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1991-05-03
Onset:1991-05-07
Submitted:1991-05-14
Entered:1991-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21045 / 1 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M130HA / 1 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 295957 / 1 2 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-07
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: pt was finishing course of Ceclor
Current Illness: resolving otitis media
Preexisting Conditions: rt hydrocele
Allergies:
Diagnostic Lab Data: Autopsy done 7May91.Provisional Anatomic Diagnoses:Consistent /w SIDS
CDC 'Split Type':

Write-up: Pt recvd immun on 3May91,@time of 4mo well baby checkup.Pt was seen in ER on 7May91 @ 630am in cardiac & respiratory arrest as an apparent SIDS death & pronounced dead /p CPR attempts.


Changed on 2/14/2018

VAERS ID: 30667 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1991-05-03
Onset:1991-05-07
Submitted:1991-05-14
Entered:1991-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21045 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M130HA / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 295957 / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-07
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: pt was finishing course of Ceclor
Current Illness: resolving otitis media
Preexisting Conditions: rt hydrocele
Allergies:
Diagnostic Lab Data: Autopsy done 7May91.Provisional Anatomic Diagnoses:Consistent /w SIDS
CDC 'Split Type':

Write-up: Pt recvd immun on 3May91,@time of 4mo well baby checkup.Pt was seen in ER on 7May91 @ 630am in cardiac & respiratory arrest as an apparent SIDS death & pronounced dead /p CPR attempts.


Changed on 6/14/2018

VAERS ID: 30667 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1991-05-03
Onset:1991-05-07
Submitted:1991-05-14
Entered:1991-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21045 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M130HA / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 295957 / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-07
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: pt was finishing course of Ceclor
Current Illness: resolving otitis media
Preexisting Conditions: rt hydrocele
Allergies:
Diagnostic Lab Data: Autopsy done 7May91.Provisional Anatomic Diagnoses:Consistent /w SIDS
CDC 'Split Type':

Write-up: Pt recvd immun on 3May91,@time of 4mo well baby checkup.Pt was seen in ER on 7May91 @ 630am in cardiac & respiratory arrest as an apparent SIDS death & pronounced dead /p CPR attempts.


Changed on 8/14/2018

VAERS ID: 30667 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1991-05-03
Onset:1991-05-07
Submitted:1991-05-14
Entered:1991-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21045 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M130HA / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 295957 / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-07
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: pt was finishing course of Ceclor
Current Illness: resolving otitis media
Preexisting Conditions: rt hydrocele
Allergies:
Diagnostic Lab Data: Autopsy done 7May91.Provisional Anatomic Diagnoses:Consistent /w SIDS
CDC 'Split Type':

Write-up: Pt recvd immun on 3May91,@time of 4mo well baby checkup.Pt was seen in ER on 7May91 @ 630am in cardiac & respiratory arrest as an apparent SIDS death & pronounced dead /p CPR attempts.


Changed on 9/14/2018

VAERS ID: 30667 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1991-05-03
Onset:1991-05-07
Submitted:1991-05-14
Entered:1991-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21045 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M130HA / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 295957 / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-07
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: pt was finishing course of Ceclor
Current Illness: resolving otitis media
Preexisting Conditions: rt hydrocele
Allergies:
Diagnostic Lab Data: Autopsy done 7May91.Provisional Anatomic Diagnoses:Consistent /w SIDS
CDC 'Split Type':

Write-up: Pt recvd immun on 3May91,@time of 4mo well baby checkup.Pt was seen in ER on 7May91 @ 630am in cardiac & respiratory arrest as an apparent SIDS death & pronounced dead /p CPR attempts.


Changed on 10/14/2018

VAERS ID: 30667 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1991-05-03
Onset:1991-05-07
Submitted:1991-05-14
Entered:1991-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21045 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M130HA / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 295957 / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-07
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: pt was finishing course of Ceclor
Current Illness: resolving otitis media
Preexisting Conditions: rt hydrocele
Allergies:
Diagnostic Lab Data: Autopsy done 7May91.Provisional Anatomic Diagnoses:Consistent /w SIDS
CDC 'Split Type':

Write-up: Pt recvd immun on 3May91,@time of 4mo well baby checkup.Pt was seen in ER on 7May91 @ 630am in cardiac & respiratory arrest as an apparent SIDS death & pronounced dead /p CPR attempts.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=30667&WAYBACKHISTORY=ON


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