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From the 6/11/2011 release of VAERS data (an older release, current is 1/7/2022):

This is VAERS ID 424958

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Case Details

VAERS ID: 424958 (history)  
Form: Version .0  
Age: 0.2  
Sex: Male  
Location: New Hampshire  
Vaccinated:2011-04-06
Onset:0000-00-00
Submitted: 2011-06-08
Entered: 2011-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3815AA / 0 LG / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915702 / 0 LG / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1525Z / 0 - / PO

Administered by: Private       Purchased by: Public
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-05-31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: No prenatal care; Prematurity 32 4/7 wks at birth
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: None reported to facility.


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