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This is VAERS ID 35080

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 35080
VAERS Form:
Age:0.2
Sex:Male
Location:Washington
Vaccinated:1991-08-30
Onset:1991-08-30
Submitted:1991-09-06
Entered:1991-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: TRI-IMMUNOL / LEDERLE 306924 / 0 LL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) M140HD / 0 RL / IM
OPV: ORIMUNE / LEDERLE 306965 / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: SIDS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-08-30
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: Instructed to use none; APAP if needed;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy
CDC 'Split Type': NONE

Write-up: Pt died-SIDS on death certificate; Pt died evening p/immun were given; MD requested vax adverse rxn report be filed; Mom states pt did not seem to have had any reactions to the immun;


Changed on 12/8/2009

VAERS ID: 35080 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Washington
Vaccinated:1991-08-30
Onset:1991-08-30
Submitted:1991-09-06
Entered:1991-10-02 1991-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: TRI-IMMUNOL DTP (TRI-IMMUNOL) / LEDERLE LEDERLE LABORATORIES 306924 / 0 LL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS M140HD / 0 RL / IM
OPV: ORIMUNE POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LEDERLE LABORATORIES 306965 / 0 - / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-08-30
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: Instructed to use none; APAP if needed;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy
CDC 'Split Type': NONE WA91618

Write-up: Pt died-SIDS on death certificate; Pt died evening p/immun were given; MD requested vax adverse rxn report be filed; Mom states pt did not seem to have had any reactions to the immun;


Changed on 5/14/2017

VAERS ID: 35080 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Washington
Vaccinated:1991-08-30
Onset:1991-08-30
Submitted:1991-09-06
Entered:1991-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 306924 / 0 LL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH M140HD / 0 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 306965 / 0 - / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-08-30
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: Instructed to use none; APAP if needed;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy
CDC 'Split Type': WA91618

Write-up: Pt died-SIDS on death certificate; Pt died evening p/immun were given; MD requested vax adverse rxn report be filed; Mom states pt did not seem to have had any reactions to the immun;


Changed on 9/14/2017

VAERS ID: 35080 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Male
Location:Washington
Vaccinated:1991-08-30
Onset:1991-08-30
Submitted:1991-09-06
Entered:1991-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 306924 / 0 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M140HD / 0 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 306965 / 0 1 - MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-08-30
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: Instructed to use none; APAP if needed;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy
CDC 'Split Type': WA91618

Write-up: Pt died-SIDS on death certificate; Pt died evening p/immun were given; MD requested vax adverse rxn report be filed; Mom states pt did not seem to have had any reactions to the immun;


Changed on 2/14/2018

VAERS ID: 35080 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Washington
Vaccinated:1991-08-30
Onset:1991-08-30
Submitted:1991-09-06
Entered:1991-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 306924 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M140HD / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 306965 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-08-30
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: Instructed to use none; APAP if needed;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy
CDC 'Split Type': WA91618

Write-up: Pt died-SIDS on death certificate; Pt died evening p/immun were given; MD requested vax adverse rxn report be filed; Mom states pt did not seem to have had any reactions to the immun;


Changed on 6/14/2018

VAERS ID: 35080 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Washington
Vaccinated:1991-08-30
Onset:1991-08-30
Submitted:1991-09-06
Entered:1991-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 306924 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M140HD / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 306965 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-08-30
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: Instructed to use none; APAP if needed;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy
CDC 'Split Type': WA91618

Write-up: Pt died-SIDS on death certificate; Pt died evening p/immun were given; MD requested vax adverse rxn report be filed; Mom states pt did not seem to have had any reactions to the immun;


Changed on 8/14/2018

VAERS ID: 35080 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Washington
Vaccinated:1991-08-30
Onset:1991-08-30
Submitted:1991-09-06
Entered:1991-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 306924 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M140HD / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 306965 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-08-30
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: Instructed to use none; APAP if needed;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy
CDC 'Split Type': WA91618

Write-up: Pt died-SIDS on death certificate; Pt died evening p/immun were given; MD requested vax adverse rxn report be filed; Mom states pt did not seem to have had any reactions to the immun;


Changed on 9/14/2018

VAERS ID: 35080 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Washington
Vaccinated:1991-08-30
Onset:1991-08-30
Submitted:1991-09-06
Entered:1991-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 306924 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M140HD / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 306965 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-08-30
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: Instructed to use none; APAP if needed;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy
CDC 'Split Type': WA91618

Write-up: Pt died-SIDS on death certificate; Pt died evening p/immun were given; MD requested vax adverse rxn report be filed; Mom states pt did not seem to have had any reactions to the immun;


Changed on 10/14/2018

VAERS ID: 35080 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Washington
Vaccinated:1991-08-30
Onset:1991-08-30
Submitted:1991-09-06
Entered:1991-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 306924 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M140HD / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 306965 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-08-30
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: Instructed to use none; APAP if needed;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy
CDC 'Split Type': WA91618

Write-up: Pt died-SIDS on death certificate; Pt died evening p/immun were given; MD requested vax adverse rxn report be filed; Mom states pt did not seem to have had any reactions to the immun;

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