Cross sectional data indicate that about four percent of elderly persons reside in nursing homes. Yet many studies, some using death certificates, show actual risk of institutionalization is upwards of 25 percent. This paper presents a death registration study that examined all deaths in North Carolina and analyzed rural and urban differences. The results indicated that the urban elderly were not, in practical terms, more likely than the rural elderly to die in hospitals and long term care facilities. Rural elderly who died in a hospital or nursing home were more likely to die in a facility outside their county of residence than were their urban counterparts. The lack of facilities may force the elderly to leave their county of residence. Rural elderly were not more likely than urban elderly to die at home or outside of health facilities. However, this does not necessarily mean rural elderly do not enjoy stronger support networks than do their urban counterparts. The introduction of a nursing home into a rural county was related to a drastic reduction in the number of deaths which occurred in hospitals outside of the county and an increase in the number of long term care facility deaths. The introduction of a local nursing home, however, did not affect the percent of in-home deaths. Several tables are included. (ABL)