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From the 8/12/2011 release of VAERS data (an older release, current is 1/7/2022):

This is VAERS ID 427623

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Case Details

VAERS ID: 427623 (history)  
Form: Version .0  
Age: 0.4  
Sex: Female  
Location: Missouri  
Vaccinated:2011-06-07
Onset:2011-06-07
   Days after vaccination:0
Submitted: 2011-07-18
   Days after onset:41
Entered: 2011-07-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 RL / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 RL / -
ROT: ROTAVIRUS (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / PO

Administered by: Private       Purchased by: Other
Symptoms: Autopsy, Death, Irritability, Sudden infant death syndrome
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-06-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: I have no idea the manufacturer of the vaccinations.
Current Illness: None
Preexisting Conditions: Lop ear/cup ear. Just cosmetic nothing serious.
Allergies:
Diagnostic Lab Data: Autopsy revealed Re-breathing/SIDS
CDC Split Type:

Write-up: Nothing major just fussy, no temperature. She ate somewhat normal, was a little fussy at the breast at times. Didn''t want to be put down.


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