PURPOSE: To identify contributing circumstances to multiple-death suicides in rural US counties from law enforcement and coroner/medical examiner narratives. METHODS: We identified multiple-death suicides as multiple suicides (i.e., two or more decedents) from the National Violent Death Reporting System (NVDRS) between 2013 and 2021. We identified rural decedents from their residence in NVDRS using federal information processing codes linked to Rural-Urban Continuum Codes. Quantitatively, we described demographic characteristics and circumstances leading to the suicide. From narrative law enforcement and coroner/medical examiner reports, we generated codes describing demographic and circumstance information using Dedoose software. We then used inductive content analysis to identify themes related to multiple-death suicides. FINDINGS: Among all multiple-death suicides (n = 50 multiple-death suicides, 99 suicide decedents), decedents were mostly non-Hispanic White (n = 90
91%), were male (n = 54
54%), and had a high school diploma or less (n = 51
56%). We identified four themes: meticulous and considerate planning (e.g., with notes, reasons, and next steps), mutual dependency (e.g., decedents were in separable), unbearable health conditions (e.g., pain, poor quality of life from chronic illnesses), and social factors of despair (e.g., financial strain, legal problems, and interpersonal violence). CONCLUSION: Developing strategies for discussing suicidal ideation and improving access to financial resources and health care may reduce multiple-death suicides in the rural United States, particularly among older adults with chronic health problems. Improving other public health initiatives such as interpersonal violence and chronic disease prevention and management may further prevent multiple-death suicides.