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From the 2/14/2017 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 307764

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Case Details

VAERS ID: 307764 (history)  
Form: Version .0  
Age: 0.34  
Sex: Male  
Location: California  
Vaccinated:2008-03-10
Onset:2008-03-11
   Days after vaccination:1
Submitted: 2008-03-22
   Days after onset:11
Entered: 2008-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2800AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF233AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0298 / 1 LA / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B70145E / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0110X / 1 - / PO

Administered by: Unknown       Purchased by: Unknown
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2008-03-11
   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: Tylenol
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Medical examiner identified cause of death as SIDS (verbal report to me).
CDC Split Type:

Write-up: Patient died of Sudden Infant Death Syndrome the day after receiving DTaP, IPV, HIB, PCV7 and Rotateq. 6/13/08 Autopsy report states COD as SIDS. Report also states slight pulmonary edema & petechial hemorrhages on thymus gland, pericardium of heart & pleurae of lungs. Patient had been placed down for nap on his left side in adult bed at daycare provider. Patient found face down & unresponsive approx 45-50 min later. CPR was started & EMS called. PMH: NSVD, no complications. Upper respiratory congestion frequently since birth & seen for cold s/s by PCP on 3/3. Otitis media 2/1 & had mild wheezing. Sibling w/recent cold symptoms. Had to be picked up early from daycare x2 the week before death due to vomiting.


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