OMAHA – Balloons in his favorite colors, black, blue, and white, drifted up from the courtyard of Underwood Tower.
His family, dressed in matching T-shirts made for the occasion, and a group of his old neighbors gathered in the scorching heat to launch the balloons into the clear August sky.
“Holla, holla!””They called out to one another.
His birth certificate listed his name as Pedtro Chappell, but no one ever addressed him as such. His family called him Pete. Friends dubbed him “Holla” after his catchphrase, “I will holla at ya later.”
Pete, the older brother of six siblings, grew up babysitting while his mother worked, and he carried that dependability with him into adulthood. He was only a phone call away when his sisters needed assistance cleaning or moving. His niece described him as the missing father figure.
But Pete was now gone, and his loved ones could not understand why — even after two months of trying to figure out what had happened in his final days.
Pete lived in the Underwood Tower, a public housing complex in central Omaha. Police discovered him dead in his apartment on the morning of July 3.
The 56-year-old died of natural causes, according to the police report. Douglas County’s coroner determined that no autopsy was required.
Last year, Pete joined the thousands of Nebraskans who died outside of a doctor’s care and without receiving an autopsy. Approximately 87% of unattended deaths are not autopsied.
When an attending medical professional fails to declare a cause of death in Nebraska, the task is always assigned to the local county attorney, a lawyer primarily responsible for prosecuting accused criminals.
Their training, resources, and approaches to the job vary greatly. Some seem to have no training at all. Nebraska law grants them the authority to decide when and how a death is investigated, with no oversight or assistance from a state medical examiner.
Despite being publicly decried as “antiquated” by experts and some local prosecutors in 2008, the system remains in place. Since then, the statewide unattended autopsy rate has been cut in half, according to a Flatwater Free Press analysis of mortality data from the United States. Centers for Disease Control and Prevention.
Pete’s family and friends were tormented by the coroner’s decision not to autopsy him, leaving them with unanswered questions about his death.
Pete is seen falling in a parking lot on security video, most likely during his last outing. Bystanders reported that he was stumbling.
Then he entered his apartment. Neighbors had not seen him for days, but they could hear his faucet running. His lifeless body emerged from Unit 419 on a gurney.
Denece Chappell, Pete’s sister, stated, “We all have to go someday, but the way it went down… nothing’s adding up.”
Denece spoke with her older brother on one of his final nights alive, and their 15-minute conversation was recorded in Pete’s old phone’s call logs.
They had planned their usual road trip to Arkansas to celebrate the Fourth of July with family.
Pete sounded healthy, Denece said. He was excited to leave.
According to an incident report, Pete died on his apartment floor a week later, discovered by two police officers and an Omaha Housing Authority employee.
When Denece heard the news, she burst into tears at work. She was sad, angry, and perplexed: How had this happened?
A few hours after Pete’s body was discovered, the police officers on the scene and the county coroner they contacted arrived with their conclusion: natural causes. Without inspecting the body, the coroner determined that an autopsy was unnecessary.
Autopsies are fairly common in Nebraska, where Pete died. An average of 16% of unattended deaths are autopsied in the four counties that make up Omaha’s metropolitan area.
In contrast, the northeast and southwest regions of the state autopsy fewer than 7% of unattended deaths on average.
Autopsy rates vary even more widely across counties.
Buffalo and Lincoln counties, separated by a 50-mile stretch of Interstate 80 in central Nebraska, had a similar number of unattended deaths in the last six years — 880 and 864, respectively.
Buffalo County ordered 116 autopsies, 66 more than Lincoln County.
Lower autopsy rates in rural areas could be attributed to a lack of resources, such as staff and funding, as well as distance from morgues, according to Robert Anderson, the CDC’s chief of mortality statistics.
However, the disparities in autopsy rates reflect the different approaches county attorneys take to their coroner duties.
Lancaster County Attorney Patrick Condon said his autopsy ordering decisions are frequently based on whether criminal charges are likely to be filed, and he relies on his intuition as a longtime prosecutor and first responders’ perspectives to guide him.
George Vinton claims to have ordered only one autopsy during his 34-year tenure as Hooker County’s chief prosecutor — and that was in the 1990s. Vinton, who is contracted by the county and lives 65 miles south in North Platte, said he delegated most of his coroner duties to the local sheriff “since I am not there a lot.”
When asked why he did not order more autopsies, Vinton stated, “There just were not any suspicious circumstances.”
Law enforcement often views death investigation through a criminal lens, but only a small percentage of deaths that should be investigated are homicides or criminal cases, according to 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 when there is any doubt about how someone died, whether it was in a car accident, at home, or in the county’s state prison.
“I do not think I have ever checked the box ‘unknown’ for someone that is died,” Beethe reported.
According to Beethe, autopsies also provide surviving family members with emotional closure and, in some cases, useful medical information.
Beethe recently ordered an autopsy on a 53-year-old who died at home from unknown causes. Pathologists discovered a previously unknown brain tumor, which their children could look out for in the future, he said.
“I think everybody wants to know why or how their loved one died,” Beethe admitted.
Understanding the cause of death is also important for public health, Keyes said, because it informs policies that prevent future deaths, such as stronger seat belt laws and recalls of dangerous 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 told the audience.
After the Independence Day fireworks had subsided, Denece Chappell selected three relatives and embarked on a search for clues about Pete’s death.
“I am boots on the ground. I am in action. “I was furious,” Denece said.
Their first stop was Good Shepherd Funeral Home, where Pete’s corpse had been delivered. Employees told them to return with an appointment to see the body, she explained.
They called the Douglas County coroner’s office from the parking lot and requested an autopsy, but acting coroner Bill Ouren denied ordering one, according to Denece. When they asked about paying for a private postmortem, Ouren said he would call back. Several family members told the Flatwater Free Press that he never did it.
Ouren said he does not recall the conversation, but the family could have contacted him again if they had previously spoken with him.
Denece felt as if they had been given an explanation — natural causes — that explained nothing. She believed that her brother was denied an autopsy because he was a poor Black man.
“I requested one, but it had already been denied. “They said no before the question was even asked,” she explained.
In an email, Ouren stated 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 declined to provide data on race or ethnicity, citing privacy concerns. However, the state submits that information to the CDC, where it is publicly available.
According to CDC data from 2018 to 2023, approximately 23% of Black people who died unattended in Douglas County had an autopsy performed, compared to approximately 13% of white, non-Hispanic people.
According to research, non-hispanic Black people are significantly more likely to die violently, such as homicide, which is often autopsied.
As Denece dug deeper, strange details emerged about Pete’s final days and the emergency response that discovered his body.
A stranger approached family members outside the gas station at 50th and Underwood, where Pete frequently purchased beer and cigarettes. He showed them grainy security footage from the gas station’s parking lot on June 28th, in which a stumbling Pete appears to narrowly avoid a reversing car before colliding with the pavement. Family members later wondered if he had suffered 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 discovered, leading family members to wonder if he died earlier than July 3. When police arrived, they discovered the kitchen sink was running.
Ed Dorsey, a neighbor, said he left a sack of hats for Pete at his door, but his friend never showed up to pick them up. He called 911 the night of July 2, but first responders did not enter Pete’s apartment until the following morning.
Dorsey said something seemed off about Pete’s apartment after his body was discovered, as if someone had gone through his belongings.
“I do not like the way it went down,” Dorsey said.
After recovering Pete’s phone, Denece discovered strange text messages from an unsaved number sent a month before his death. The unknown texter claimed Pete had taken advantage of their generosity by calling him a racial slur.
“I hope you are rotten in hell,” the texter wrote on May 31.
The family also discovered a puzzling error in the incident report filed by the officers who discovered Pete’s body.
According to the report, Katrina Chappell, another of Pete’s sisters, arrived on the scene, but she informed Flatwater that she was away on a trip to Grand Island at the time. Her daughter, Quanna, who was present and spoke with police, was not mentioned in the report.
Lt. Neal Bonacci, spokesman for the Omaha Police Department, said a clerical error is likely to blame, noting that body camera footage shows an officer speaking with Katrina over the phone. Bonacci refused to allow Flatwater access to the video.
According to the report, Katrina told officers that Pete was a severe alcoholic and smoker, which Katrina and Quanna denied. Pete’s alleged alcoholism influenced officers’ conclusion that he died of natural causes, which ultimately appeared on his death certificate.
Denece pondered: Even if Pete was a heavy drinker and smoker, why should this prevent him from being autopsied?
All of it — the surveillance video, the running faucet, the strange texts, the police blunder — led Denece deeper into a rabbit hole but got her no closer to explaining Pete’s death.
Months later, Denece still carried a black folder containing police reports, call logs, and some of Pete’s belongings. She told anyone who would listen about the results of her amateur investigation, but she questioned why the burden had fallen on her.
“I mean, why am I playing Inspector Gadget?”
To save money, state lawmakers eliminated individually elected coroners more than a century ago, instead assigning their duties to each county’s top prosecutors. At the time, a coroner sued the state, claiming that “county attorneys cannot give proper attention.”
The suit was unsuccessful, and the law has remained relatively unchanged in the 110 years since.
Over the years, experts and legislators have described Nebraska’s system as “quite primitive,” “antiquated,” and “inadequate.”
Bills to establish state medical examiners failed in 1980 and 1999 due to cost concerns, and the issue remained quiet until the Omaha World-Herald conducted an investigation in 2008.
The study discovered that only 27% of deaths handled by coroners between 2000 and 2004 were autopsied. At the time, county attorneys were not required to receive any training before serving as coroners.
A year after the investigation, the Nebraska Legislature passed a law requiring coroners to complete death investigation training within one year of starting their jobs.
Some Nebraska county attorneys, including Beethe, attend additional training at conferences.
Melodie Bellamy, president of the Nebraska County Attorneys Association, stated that the organization’s training offerings have improved over the last two decades.
However, one county attorney, Vinton, told Flatwater that he had never received coroner-specific training. The Hooker County Attorney has not ordered an autopsy in thirty years.
Douglas County Attorney Don Kleine, who chairs the statewide County Attorney Standards Advisory Council, believes that county attorneys elected or contracted prior to the 2009 law were never required to complete death investigation training. “But that is not what we want,” he explained.
While the 2009 law may have resulted in more training, it has not led to an increase in autopsies. In the six years of available data, autopsies were performed on only about 12.5% of deaths handled by coroners.
Meanwhile, other states have begun to abolish coroner positions in favor of medical examiners, or have established hybrid systems that combine county coroner and statewide medical examiner offices for oversight and assistance.
Medical examiner systems are generally regarded as superior because they require forensic pathologists, according to Anderson of the CDC. Coroners are often not medical professionals.
County attorneys continue to serve as coroners in Nebraska, as well as a few counties in Washington state and three counties in New York. However, the other isolated holdouts are disappearing.
In New York, counties have switched to medical examiners as state lawmakers push to “end the archaic practice” of electing coroners entirely. Additionally, as of January 1, 2025, Washington prosecutors are no longer permitted to serve as coroners in the few remaining counties.
With these changes, Nebraska’s 93 counties may soon be the only ones in the country where elected prosecutors also serve as coroners.
As July progressed, the Chappells disagreed about whether they should continue to seek answers. Some members simply wanted to move on and honor Pete’s memory.
Denece was still desperate to understand, clutching her folder containing Pete’s belongings and investigative documents.
“I never stop thinking about Pete. “It is sad,” she stated. “I am still not satisfied, but there is only so much I can do.”
The family eventually raised funds through a crowdsourcing campaign and had Pete cremated, eliminating the possibility of an autopsy.
Unanswered questions about how a loved one died can complicate or prolong the grieving process, according to Julie Bierman, a therapist at Counseling Connections and Associates in Omaha.
An autopsy cannot bring back a deceased relative, but it can provide closure, she explained.
“It is like having a puzzle with just a few pieces missing. How satisfied are you with that?” said Quanna, Pete’s niece.
Pete, a 56-year-old Black man from Omaha, had a one-in-four chance of being autopsied based on his age, race, gender, and the location of death.
Men are twice as likely as women to have autopsies in Nebraska.
At the national level, men are more likely to be autopsied than women because they are more likely to die from injury-related causes such as drug overdose, homicide, and suicide, according to Anderson, the mortality statistician.
After the age of 40, autopsy rates in Nebraska and across the country drop dramatically. Anderson explained that when young people die unexpectedly, the cause is often unknown.
When autopsies are ordered in Nebraska, they are almost always performed at the Douglas County morgue, which is the state’s only public autopsy facility, Kleine explained.
It is a simple building in midtown Omaha shared with the organ donation nonprofit Live On Nebraska, which built it in 2018.
On a rainy November Monday, there were eight bodies awaiting autopsy. The majority were local, but one had traveled about two hours from Madison County. Another person had traveled three and a half hours from Harlan County.
Kleine has seen cases sent from as far away as Scotts Bluff County, approximately 450 miles from Omaha.
They are cared for by four rotating forensic pathologists who each contract with Douglas County for one or two days per week. Kleine said the county is fortunate to have so many forensic pathologists, as they are in short supply.
An autopsy costs Douglas County approximately $2,500, but faraway counties frequently pay hundreds more to transport bodies to Omaha.
Nebraska county attorneys order autopsies, which are almost entirely funded by their county budget. The state reimburses for certain autopsies, such as those performed on children under the age of five and those performed on overdose victims.
Kleine said some of his rural colleagues face budget constraints and county boards complain about the cost of autopsies. Ideally, he said, money should never be considered.
“It can not be a case of, ‘Gosh, should I do this autopsy or not, or will the county board be upset because it is going to cost so much?'” Kleine stated.
Nebraska’s few existing laws are vague, leaving plenty of room for interpretation.
Kleine believes that more investigation protocols, laws, and training for specific cases, particularly when domestic violence is a possible cause, could assist county attorneys in performing their duties effectively.
“Laws may compel county boards in smaller jurisdictions to acknowledge their lack of options.” “We have to put up the money to get this done,” Kleine stated.
One of the white balloons that floated up from Underwood Tower that August day contained a Sharpie message from his friend Ed Dorsey: “We will holla at you later.”
The balloons faded out of sight gradually, the blue balloons blending into the cloudless sky, the black balloons becoming indistinguishable specks.
Eventually, only the white balloons remained visible. Pete’s family and neighbors slowly turned away, returning to the patio and their conversations.
Dorsey stared at his balloon, squinting against the harsh sun. He said they looked like stars from so high in the sky.
“Peter, you are in the stars now!”He called.
It took months for the Chappell family to feel ready to collect Pete’s ashes. Denece’s sisters shared their portions. Denece explained that releasing the balloons and spreading his ashes was cathartic for her family because they had cared for him.
Denece, on the other hand, is still holding on to Pete’s ashes, which she keeps at home, as well as her doubts.
Her phone calls have ended in dead ends. She was unable to obtain any additional security camera footage from that day, contact the officers listed in the police report, or see her brother’s body.
She feels better now that he is at peace, she said in a January interview. But she will never know what happened.
“There is big question marks still in my head right now,” she said. “There is still nothing, no answers.”
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