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STATE OF NEBRASKA
<br />WHEN THIS i` COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />7/21/2021
<br />LINCOLN, NEBRASKA
<br />202106680
<br />VITAL
<br />t'ct.?
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are flied with the county court in the county where the decedent resided at the time of death.;
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Barry Alan Skalberg
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo„ Day, Yr.)
<br />June 27, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Norfolk, Nebraska
<br />(Yrs.)
<br />47
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 25, 1973
<br />7. SOCIAL SECURITY NUMBER
<br />506-02-5892
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACIUTV.NAME (If not Institution, give street and number)
<br />4148 Fleetwood Rd.
<br />❑ ER/Outpatient ® Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a.RESIDENCESTATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />4148 Fleetwood Rd.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY` LIMITS
<br />® YES 0 No
<br />10a MARITAL: STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Traci Lynn Hines
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert Skalberd
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Betty Kliment
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Traci Lynn Skalberd
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />fil Butlai ©Donation
<br />0 ©Entombment
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16b. LICENSE NO.
<br />1071
<br />113c. DATE (Mo., Day, Yr.)
<br />July 3, 2021
<br />Cremation
<br />0 Removal- ❑Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Hillcrest Memorial Park Cemetery Norfolk Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Ali Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PART I. Enter the chain of events- 4iseases, injuries, or complications4hat directy caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE Mina' a) Metastatic Malignant Melanoma Of Skin
<br />disease or condition Mashing
<br />In death)
<br />Enter only one cause on a line. Add additional lines if necessary.
<br />-
<br />onset to death
<br />4 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />on fine a.
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(diarist* or injury that initiated
<br />onset to death',
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18, PART11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resultingin the underlying cause given In PART I.
<br />Steroid Inducted Hyperglycemia, Asthma, Hyperlipidemia, Hypertension
<br />19. WAS MEDICAL EXAMINEk
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF
<br />El
<br />0
<br />FEMALE:
<br />Non pregnant within peat year
<br />Pregnant at'.time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ® NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />Suicide ❑Could not be determined
<br />ID Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />225,' DATE OFINJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Spec fy)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />SJune
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />27, 2021
<br />S
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />$ v O /
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />July 20, 2021
<br />23c. TIME OF DEATH
<br />06:08 PM
<br />& i C r
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />u O
<br />$ El
<br />z
<br />f my knowledge, death occurred at the ne, date and place
<br />29d. 'tin 11* heat oti
<br />And due to the causes) stared. (Signature and Title)
<br />Adam Brosz, MD
<br />Z
<br />B §se
<br />~ o Is
<br />24e. On the basis of examination and/or investigation, In my opinion ed! OOcurred at
<br />de
<br />Incthe time, data and place and due to the causes) stared. (Signature and Tide)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO'
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES 0 NO
<br />27. NAME, TttI E AND ADDRESS OF CERTIFIER (Type or Print
<br />_ Adam Brosz, MO, 2444 W. Faidley Avenue, Grand
<br />Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATUREL__36k-/Z 0�
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 21, 2021
<br />CO
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