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From the 12/31/2003 release of VAERS data (an older release, current is 1/7/2022):

This is VAERS ID 79601

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Case Details

VAERS ID: 79601 (history)  
Form: Version .0  
Age: 0.2  
Sex: Female  
Location: Utah  
Vaccinated:1995-11-03
Onset:1995-11-04
   Days after vaccination:1
Submitted: 1995-11-07
   Days after onset:3
Entered: 1995-12-01
   Days after submission:24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPH: TETRAMUNE / LEDERLE 428039 / 0 LL / IM
HEP: ENGERIX-B / SMITHKLINE 1664B2 / 1 RL / IM
IPV: IPV / MERIEUX INST L0227 / 0 RL / SC

Administered by: Private       Purchased by: Unknown
Symptoms: CYANOSIS, STUPOR
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-04
   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: Dimetapp, APAP
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: baby found blue & unresponsive


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