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We report significant pathological findings from 250 stranding investigations of 20 cetacean species in the Pacific Islands region between 2006 and 2022. Full or partial necropsies of 196 of the 250 stranding cases (78.4%) resulted in a diagnosis or multiple diagnoses associated with death in 126 cases. Natural disease accounted for 60.3% of stranded animals; approximately half were in poor body condition at time of death due to chronic illness. Morbillivirus and Brucella sp. infections caused mortality in eleven species, including striped dolphins and the Longman’s beaked whale. Toxoplasma infection, of anthropogenic cause in Hawaiʻi, led to the deaths of two spinner dolphins. Pygmy and dwarf sperm whales, beaked whales and pilot whales showed heavy parasitism by nematodes, cestodes and trematodes. Approximately 12.7% of stranded individuals were perinates/neonates, with three cases of dystocia with maternal mortality. Anthropogenic trauma was observed in 30.2% of strandings. In seven Cuvier’s beaked whales, cranial and/or microvascular hemorrhages were categorized as trauma. Vertebral and skull fractures were attributed to direct vessel strikes for two pygmy sperm whales, a Cuvier’s beaked whale, a humpback whale calf and a striped dolphin. Blast trauma was observed in three Fraser’s dolphins that were part of an uncommon stranding event. Significant plastic debris, and/or fishery debris were found in stomachs of six species and fatal fishhook penetration occurred in a Submitted in Support of the U.S. Navy’s 2023 Annual Marine Species Monitoring Report for the Pacific STANDARD FORM 298 Back (Rev. 8/98) bottlenose dolphin. This study highlights the value of carcass examinations in a region inhabited by small island associated populations where carcass recovery rates are low, and cetaceans face an array of natural and anthropogenic threats.