Balloons in his favorite colors — black, blue and white — drifted up from the courtyard at Underwood Tower. 

His family, wearing matching T-shirts made for the occasion, and a group of his old neighbors gathered in the scorching heat to release the balloons into a clear August sky.

“Holla, holla!” they called out to each other.

His birth certificate read Pedtro Chappell, but nobody called him that. Family knew him as Pete. Friends knew him as “Holla” — for his catchphrase “I’ll holla at ya later.”

An older brother to six siblings, Pete grew up babysitting when mom was at work, and he carried that dependability with him through a challenging adulthood. He was only a call away when his sisters needed help cleaning or moving. His niece said he was like the dad she didn’t have.

But now, Pete was gone and his loved ones couldn’t understand why — even after two months spent trying to find out what had happened in his final days.

Pete lived in Underwood Tower, a public housing complex in central Omaha. That’s where police found him dead in his apartment on the morning of July 3.

The 56-year-old died from natural causes, the police concluded in their report. Douglas County’s coroner decided no autopsy was needed.

Pete became one of the thousands of Nebraskans who died outside of a doctor’s care and did not receive an autopsy last year. On average, 87% of unattended deaths aren’t autopsied.

In Nebraska — and only Nebraska — when an attending medical professional doesn’t declare a cause of death, the task always falls to the local county attorney, a lawyer primarily responsible for prosecuting accused criminals. 

Their training, access to resources and approaches to the job vary widely. Some appear to have no training at all. Nebraska law gives them authority to decide when and how a death is investigated, without oversight or assistance from a state medical examiner.

It’s a system that remains in place despite experts and some local prosecutors publicly decrying it as “antiquated” in 2008. Since then, the statewide unattended autopsy rate has dropped by about half, according to a Flatwater Free Press analysis of mortality data from the U.S. Centers for Disease Control and Prevention.

The coroner’s decision not to autopsy Pete left his family and friends tormented with questions about his death and no way to answer them.

Security video shows Pete falling in a parking lot during what was likely his last outing. Bystanders said he was stumbling.

Then he went into his apartment. Neighbors didn’t see him for days, but they could hear his faucet running. His lifeless body emerged from unit 419 on a gurney. 

“We all gotta go some day, but just the way it went down … nothing’s adding up,” said Denece Chappell, Pete’s sister.

****

NEBRASKA IN CONTEXT BOX

Nebraska autopsies about 12.5% of deaths that were unattended, meaning outside of medical settings. In neighboring Colorado, about 25% are autopsied.

Nationally, about 13.3% of unattended deaths are autopsied, according to FFP analysis of CDC data. Nebraska ranks in the bottom half nationally – 30 states and D.C. have higher unattended autopsy rates. 

Denece talked to her big brother on one of his last nights alive, their 15-minute exchange recorded in the call logs of Pete’s old phone.

They were planning their usual road trip to Arkansas to belatedly celebrate the Fourth of July with family.

Pete sounded like he was in good health, Denece said. He was excited to go.

A week later, two police officers and an employee of the Omaha Housing Authority found Pete dead on his apartment floor, according to an incident report.

When Denece heard the news, she broke down crying at work. She felt sad, angry and confused: How did this happen?

The police officers on scene and the county coroner they phoned came up with their answer a few hours after Pete’s body was discovered: natural causes. Without examining the body, the coroner concluded an autopsy wouldn’t be necessary.

****

Where Pete died, autopsies are relatively common — at least by Nebraska standards. The four counties containing Omaha’s metro area conduct autopsies on an average of 16% of unattended deaths.

By contrast, the northeast and southwest regions of the state autopsy less than 7% of unattended deaths on average.

Autopsy rates vary even more widely among individual counties.

Separated by a 50-mile stretch of Interstate 80 in central Nebraska, Buffalo and Lincoln counties saw a similar number of unattended deaths over six recent years — 880 and 864, respectively.

Buffalo County ordered 116 autopsies — 66 more than Lincoln County.

Lower autopsy rates in rural areas may reflect a lack of resources, like staff and funding, and distance from morgues, Robert Anderson, chief of mortality statistics at the CDC.

But those disparities in autopsy rate also reflect the differing philosophies county attorneys bring to their coroner duties.

Lancaster County Attorney Patrick Condon said his autopsy ordering decisions often hinge on whether criminal charges could be involved, letting his intuition as a longtime prosecutor and the perspective of first responders guide him.

George Vinton said he has ordered just one autopsy during his 34-year tenure as the head prosecutor in sparsely populated Hooker County — and that was back in the 1990s. Vinton, who is contracted by the county and based 65 miles south in North Platte, said he delegates most of his coroner duties to the local sheriff “since I’m not there a lot.”

When asked why he didn’t order more autopsies, Vinton said, “There just weren’t any suspicious circumstances.”

Law enforcement tends to view death investigation through a criminal lens, but only a small percentage of deaths that should be investigated are homicides or criminal cases, said Kelly Keyes, a forensic scientist and president of the International Association of Coroners and Medical Examiners.

Johnson County Attorney Benjamin Beethe said he orders autopsies if there’s any doubt about how someone died, whether in a car crash, at home or in the county’s state prison.

“I don’t think I’ve ever checked the box ‘unknown’ for someone that’s died,” Beethe said.

Autopsies also provide surviving family members emotional closure, Beethe said, and sometimes useful medical information.

Recently, Beethe ordered an autopsy on a 53-year-old who died at home of uncertain causes. Pathologists found a previously undiscovered brain tumor — something their kids could look out for down the road, he said.

“I think everybody wants to know why or how their loved one died,” Beethe said. 

Understanding the cause of death is important for public health, too, Keyes said, because that data informs policies that prevent further deaths — like stronger seat belt laws and recalls on unsafe baby cribs.

“A lot of that comes from, unfortunately, fatal situations where somebody has died and a medical examiner or coroner's office has collected that data,” Keyes said. 

NEBRASKA IN CONTEXT BOX

Nebraska is one of seven states that does not have some type of medical examiner’s office. Of those states, Louisiana and Kansas require coroners to be medical professionals.

Only Nebraska, Nevada, Idaho, South Dakota and Wyoming, by state law, do not require any level of death investigator to be a medical professional.

****

Hours after the Independence Day fireworks subsided, Denece Chappell picked three relatives and set out on a quest for clues about Pete’s death.

"I'm boots on the ground. I'm in action. I was pissed off,” Denece said.

Their first stop was Good Shepherd Funeral Home where Pete’s corpse had been sent. Employees told them to come back with an appointment to see the body, she said.

From the parking lot, they called the Douglas County coroner’s office and asked for an autopsy, but acting coroner Bill Ouren said he had no reason to order one, Denece said. When they inquired about paying for a private postmortem, Ouren said he would call them back. He never did, several family members told the Flatwater Free Press.

Ouren said he doesn’t remember the conversation, but added that the family could have reached out again if they had previously spoken to him.

To Denece, it felt like they had been fed an explanation — natural causes — that explained nothing. The denial of an autopsy, she believed, came because her brother was a poor Black man.

“I requested one, but it was already denied. They already said no before the question was even asked,” she said.

Ouren said in an email that a deceased person’s “financial status, race, gender (or any other personal characteristics, for that matter) have absolutely nothing to do with the decision to conduct an autopsy.”

The Nebraska Department of Health and Human services refused to provide data related to race or ethnicity, citing privacy concerns. But the state reports that data to the CDC, where it is publicly available.

About 23% of Black people who died unattended in Douglas County received an autopsy, compared to about 13% of white, non-hispanic people, according to CDC data from 2018 to 2023.

Research shows that non-hispanic Black people are significantly more likely to die violently, like by homicide — causes of death often autopsied.

As Denece dug further, odd details started to flood in about Pete’s final days and the emergency response that turned up his body.

A stranger approached family members outside the gas station at 50th and Underwood where Pete often bought beer and cigarettes. He showed them grainy June 28 security footage from the gas station’s parking lot in which a stumbling Pete appears to narrowly avoid a reversing car before falling hard on the pavement. Family members wondered later if he might have sustained a head injury.

Tenants at Underwood Tower told Denece that a faucet in his apartment had been running for several days before his body was found, making family members wonder if he died sooner than July 3. Police found the kitchen sink running when they arrived. 

Neighbor Ed Dorsey said he left a sack of hats for Pete at his door, but his friend never emerged to pick them up. He called 911 the night of July 2, but first responders didn’t enter Pete’s apartment until the next morning.

Dorsey said something looked off about Pete’s apartment after his body was found — like someone had been searching through his belongings.

“I don’t like the way it went down,” Dorsey said.

After recovering Pete’s phone, Denece found bizarre text messages from an unsaved number sent a month before his death. The mystery texter said Pete had taken advantage of their generosity and called him a racial slur.

“I hope you’re rotten in hell,” the texter wrote on May 31.

The family also spotted a puzzling inaccuracy in the incident report filed by police who found Pete’s body.

The report states that Katrina Chappell, another of Pete’s sisters, arrived on scene, but she told Flatwater she was out of town on a trip to Grand Island at the time. Her daughter Quanna, who was there and spoke to police, wasn’t mentioned in the report.

Omaha Police Department spokesman Lt. Neal Bonacci said a clerical error is likely to blame, noting that body camera footage shows an officer speaking with Katrina on the phone. Bonacci declined to give Flatwater access to the video.

The report also states that Katrina told officers Pete had been a severe alcoholic and a smoker, which Katrina and Quanna denied they said. Pete’s supposed alcoholism drove officers’ judgment that he died of natural causes and ultimately landed on his death certificate.

Denece wondered: Even if Pete was a heavy drinker and smoker, why should that disqualify him from being autopsied? 

All of it — the surveillance video, the running faucet, the strange texts, the police misstep — plunged Denece further down a rabbit hole but brought her no closer to explaining Pete’s demise.

Months later, Denece continued to carry around a black folder containing police reports, call logs and some of Pete’s belongings. She told anybody who would listen about the findings of her amateur investigation, but wondered why the burden had fallen to her.

“I'm like, why am I playing Inspector Gadget?”

****

More than a century ago, state lawmakers did away with individually elected coroners, assigning their duties to each county’s top prosecutors to save money. At the time, a coroner sued the state, arguing that “county attorneys cannot give the proper attention.”

The suit was unsuccessful, and in the 110 years since, that law has hardly been touched.

Over the years, experts and legislators have called Nebraska’s system “quite primitive,” “antiquated” and “inadequate.”

Bills to establish state medical examiners in 1980 and 1999 collapsed due to cost concerns, and the issue went quiet until a 2008 investigation by the Omaha World-Herald.

The paper found that only 27% of deaths handled by coroners from 2000 to 2004 were autopsied. At the time, no training was required of county attorneys to serve as coroners. 

A year after the investigation, the Nebraska Legislature passed a law requiring coroners to complete a death investigation training within one year of starting the job.

Some Nebraska county attorneys, like Beethe, attend extra training at conferences.

The Nebraska County Attorneys Association has improved its training offerings over the past two decades, said Kearney County Attorney Melodie Bellamy, the association’s president.

But one county attorney, Vinton, told Flatwater he has never done coroner-specific training. The Hooker County Attorney hasn’t ordered an autopsy in 30 years.

Douglas County Attorney Don Kleine, who chairs the statewide County Attorney Standards Advisory Council, said it’s likely that county attorneys elected or contracted before the 2009 law  have never been made to do death investigation training. “But that’s not what we want,” he added.

While the 2009 law may have resulted in more training, it hasn’t led to more autopsies. In the past six years of available data, only about 12.5% of deaths handled by coroners involved autopsies.

NEBRASKA IN CONTEXT BOX

Training standards vary widely by state. About 59% of states that have coroners, including Nebraska, define some requirements the coroner must meet after taking office.

Most laws define specific standards or programs and minimum continuing education hours.

In Nebraska, the state’s County Attorney Standards Advisory Council sets and monitors required training. The council demands county attorneys do 20 hours of continuing education each year, but there is no requirement for coroner-specific training. 

Meanwhile, other states have started abolishing coroner positions in favor of medical examiners, or created hybrid systems of county coroners and statewide medical examiner offices for oversight and assistance.

Generally, medical examiner systems are considered superior because they’re usually required to be forensic pathologists, said Anderson with the CDC. Coroners often aren’t medical professionals.

County attorneys still double as coroners in Nebraska, as well as a handful of counties in Washington state and three counties in New York. But those other isolated holdouts are disappearing.

In New York, counties have individually switched to medical examiners amid a push by state lawmakers to “end the archaic practice” of electing coroners altogether. And, as of Jan. 1 2025, Washington prosecutors are no longer allowed to serve as coroner in the few remaining counties.

Those changes may soon leave Nebraska’s 93 counties as the only in the country where elected prosecutors double as coroners.

****

As July stretched on, the Chappell family split on continuing to push for answers. Some members just wanted to let it go and lay Pete’s memory to rest.

Denece was still desperate to understand, holding onto her folder of Pete’s belongings and documents from her investigation.

“There’s not a day go by I don’t think about Pete. It’s sad,” she said. “I’m still not satisfied, but there’s only so much I can do.”

Eventually, the family crowd-funded money and had Pete cremated, removing any possibility of an autopsy.

Having unanswered questions about how a loved one died can complicate or prolong grieving, said Julie Bierman, a therapist at Counseling Connections and Associates in Omaha.

An autopsy doesn’t bring back a deceased relative, but it can provide closure, she said.

“It's kind of like having a puzzle when it's just pieces missing. … How are you satisfied with that?” said Pete’s niece Quanna.

Pete, a 56-year-old Black man living in Omaha, had, based on his age, race, gender and where he died, about a 1 in 4 chance of being autopsied.

Men are two times more likely than women to receive autopsies throughout Nebraska. 

At the national level, men are more likely to be autopsied too, because they’re more likely to die of injury-related causes like drug overdose, homicide and suicide than women, said Anderson, the mortality statistician.

Autopsy rates decline sharply after the age of 40 in Nebraska and across the country. When young people die suddenly, Anderson said, the cause is often unclear.

And when autopsies are ordered in Nebraska, they are almost always performed at the Douglas County morgue, because it is the state’s only public autopsy facility, Kleine said.

It’s an unassuming building in midtown Omaha, shared with organ donation nonprofit Live On Nebraska, which built it in 2018. 

On a rainy November Monday, there were eight bodies waiting to be autopsied. Most were local, but one had traveled about two hours from Madison County. Another had traveled three and a half hours from Harlan County.

Kleine has seen cases sent from as far away as Scotts Bluff County, around 450 miles from Omaha.

They’re tended to by four rotating forensic pathologists who each contract with Douglas County to work one or two days a week. The county is lucky to have that many, Kleine said, because forensic pathologists are in short supply.

An autopsy costs Douglas County about $2,500, but faraway counties often pay hundreds more to transport bodies to Omaha. 

NEBRASKA IN CONTEXT BOX

Nebraska is one of 23 states that define at least one instance where an autopsy must be done. Of those, 11 states only require autopsies for children who die unexpectedly.

Nebraska and five others also require autopsies for people who die in law enforcement custody.

Several states, not including Nebraska, require autopsies if a crime may have been committed.

Autopsies ordered by Nebraska county attorneys are funded almost entirely through their county’s budget. The state offers reimbursements for certain autopsies, like children under 5 and overdoses.

Kleine said some of his rural colleagues struggle with budgetary constraints and county boards griping about the cost of autopsies. Ideally, he said, money should never be a factor. 

“It can't be a question of whether, ‘gosh, should I do this autopsy or not, or is the county board going to be upset because it's going to cost so much?’” Kleine said.

Nebraska’s few existing laws are vague, leaving ample room for interpretation. 

More investigation protocols, laws and training for specific cases, especially when domestic violence is a possible cause, could help county attorneys do their jobs well, said Kleine. 

“...and maybe (laws could) force even county boards in smaller jurisdictions to say, ‘Hey, look, we don't have a choice here. We have to pony up the money to get this done,’” Kleine said. 

****

One of the white balloons bobbing up from Underwood Tower that August day carried a Sharpie message from his friend Ed Dorsey: “We’ll holla at you later.”

Slowly, the balloons blinked out of sight, first the blue balloons blended with the cloudless sky, then the black balloons became indistinguishable specks.

Eventually only the white balloons were visible. Pete’s family and neighbors slowly turned away, back to the patio and back toward conversations with each other.

Dorsey kept watching his balloon, squinting against the harsh sun. They looked like stars, he said, so high up in the sky.

“You’re in the stars now, Pete!” he called.

It took the Chappell family months after that day to feel ready to pick up Pete’s ashes. Denece’s sisters spread their portions. For her family, releasing the balloons and spreading his ashes felt cathartic, Denece said, because they had taken care of him.

But Denece is still holding on; to Pete’s ashes, which she keeps in her home, and to her doubts.

Her phone calls have turned into dead ends. She couldn’t get additional security camera footage from that day, couldn’t reach the officers listed in the police report and didn’t get to see her brother’s body.

She does feel better now, knowing he’s at peace, she said in a January interview. But she’ll never be sure what happened.

“There’s big question marks still in my head right now,” she said. “There’s still nothing, no answers.”

The Flatwater Free Press is Nebraska’s first independent, nonprofit newsroom focused on investigations and feature stories that matter.