Pallbearers unload a coffin at Smith Cemetery in Strunk, Ky. Over the last 15 years, the state’s McCreary County has seen a 75 percent increase in the mortality rate for white women between the ages of 35 and 59, one of the highest increases in the nation, according to a Washington Post analysis of national mortality rates. (Bonnie Jo Mount/The Washington Post)

UNNATURAL CAUSES SICK AND DYING IN SMALL-TOWN AMERICA | Since the turn of this century, death rates have risen for whites in midlife, particularly women. The Washington Post is exploring this trend and the forces driving it. Read part one, part two, part three and part four.

She died alone in the middle of the night, and her body was swiftly autopsied, embalmed and carted 135 miles to a remote Kentucky county where she had been raised. There, Dan Ridener waited. The undertaker watched as the Cadillac Escalade pulled up and the corpse was wheeled inside. Then he removed the blanket covering McCreary County Funeral Home’s newest arrival.

Curly, blond hair. A haggard face. Dark circles under both eyes. Nails bitten and bloodied. A provisional report of death came with the body.

“Name: Lois A. Maxwell.”

“Age: 44.”

“Race: W.”

“Sex: F.”

The document didn’t say anything about a cause of death, but Ridener didn’t need it to know what had happened: Another white woman had died in what should have been the prime of her life. Across America, especially in rural and working-class communities, death rates have been accelerating among middle-aged white women for a generation, and in McCreary County, which is 91 percent white, no one knows this better than the undertaker, who now lifted Maxwell’s body onto an aluminum table.

“She doesn’t look 44,” an assistant said, snapping on blue latex gloves.

“She looks older,” said Ridener, who did the same.

“She looks a lot older than that,” the assistant said. “She looks 60, I’d say.”

Ridener peered down at the body. As with most of the people who end up on his table, he was familiar with Maxwell and the troubled life she had led. In the last decade, Kentucky courts had convicted her of 11 separate drug- and alcohol-related charges. At the time of her death, she was facing four more.

“Drugs,” Ridener said, looking at the effects. He placed a fresh sheet over Maxwell’s body, and then, knowing that nothing dries out skin like death, his assistant began slathering moisturizing cream on her face to prepare her for the coming arrival of her family.

Customers eat at a diner-style restaurant in Whitley City, Ky. A study by a research center at the University of Washington found that McCreary County women are more likely to be obese than those of previous generations. (Bonnie Jo Mount/The Washington Post)

So there would be a funeral in McCreary County, another funeral, which, in and of itself, was nothing remarkable. In a county of 18,000 people in southern Kentucky, about 250 of them die each year, a number that hasn’t changed significantly in decades.

What has changed, however, is the age of the people dying. Over the last 15 years, McCreary County has seen a 75 percent increase in the mortality rate for white women between the ages of 35 and 59, one of the highest increases in the nation, according to a Washington Post analysis of national mortality rates. The analysis also showed that the mortality rate for similarly aged white women nationally increased 23 percent; for white men increased 16 percent; for black women decreased 10 percent; for black men decreased 20 percent; for Hispanic women decreased 11 percent; and for Hispanic men decreased 16 percent.

Another study, by a research center at the University of Washington, found that McCreary County women are more likely to be obese and engage in life-shortening behaviors such as binge drinking than in previous generations, and a separate tally kept by the funeral home showed that, in 2013, 20 white women younger than 60 were buried; last year it was 31.

Those deaths have all been charted by Debbie Murphy, the owner of two of the county’s three funeral homes, where she employs Ridener as her undertaker. She maintains spreadsheets that enumerate every burial in McCreary County, and, like Ridener, knows most of the people, too.

Dan Ridener, who serves as undertaker for McCreary County Funeral Home, drives a hearse to a service. (Bonnie Jo Mount/The Washington Post)

“She killed herself,” she said to Ridener one morning, scanning the lists.

She pointed to another name. “She drank herself to death.”

She pointed to two more names. “Jerry and Amanda.”

“He actually shot her,” Ridener said. “And then shot and killed himself.”

“And they were in the same casket together,” Murphy said.

“And they’re my cousins,” Ridener added.

“That was drugs,” he said of another, as Murphy nodded.

“Drug use,” he said of another.

“I don’t remember her,” Murphy said of a 49-year-old. “I don’t think she was drugs, though, was she?”

“She wasn’t drugs. She was just lice,” Ridener said, and not long after that came word of another death, this one a 59-year-old woman. He got behind the wheel of one of Murphy’s three hearses and drove through a landscape that in his 48 years has gone from a place of promise to one where, according to Census Bureau and state figures, nearly 40 percent of households receive food stamps and 77 percent of students qualify for free or reduced school lunches.

He passed turnoffs for once-thriving coal mines, the last of which stopped producing in 1995. He passed by desolate factory towns where hundreds once found work; the main row of restaurants, all of them fast food; the local grocery store that’s always selling out of Mountain Dew; and skinny roads leading to cemeteries where the county gravedigger has found syringes in the grass.

Now as he drove past Blue John Road, where in 2008 the county coroner was arrested for drug use after being found slumped over the wheel of an official Chevrolet Suburban, a syringe in his hands, Ridener found himself thinking there wasn’t a single family in McCreary County that hasn’t been affected by drugs, including his own daughter’s. He remembered a day when he got a phone call from his 8-year-old grandson. “He said, ‘I need you to come pick me up. Dad is high. He’s got this white powder laying there.’ ” He remembered going to the house and his grandson coming outside. “He said, ‘I didn’t want you to think I was lying to you, so I brought you proof.’ ” He remembered the boy opening his clenched fist, the boy’s surprise that the powder had disappeared, his own fear that the boy had absorbed the powder through his skin, the trip to the emergency room, his threat to his son-in-law that, “If anything happens to my grandson, I’m going to kill you,” and his relief when his daughter and grandson moved out, not that they’ve had an easy time of it since.

He now parked the hearse outside Lake Cumberland Regional Hospital and went up to a room on the fourth floor. He expected to meet a family crowded around the remains. Instead, he found a dead woman by herself.

The body was that of a woman named Betty West, who was born in McCreary County and lived in a home of corrugated iron and plywood, supported herself with disability checks, died of lung cancer, and whose life had come down to sitting in a brown recliner, watching television and smoking cigarette after cigarette.

“They don’t think that smoking really will kill you,” a nurse, Desiree Middleton, 32, now said to Ridener. “It’s one of those teenage mind-sets.”

There was a whiteboard with four phone numbers hanging on a wall. Each belonged to one of West’s family members. When West was about to die, Middleton said, she had started calling the numbers even though it was 4 a.m.

“I called her husband,” Middleton said. “We tried calling every kid, and I even resorted to calling grandchildren, and got nothing. But I stayed with her, and that’s what I’m here for.” She looked down at West, whose face was wrinkled and worn. “That is what makes it harder. She looks a lot older than 59.”

“We got a 44-year-old yesterday,” Ridener said. “And she looks a lot older than 44.”

Ridener hoisted West’s body onto a gurney and zipped around it a maroon body bag emblazoned with “McCreary Funeral Home.” Then he wheeled the gurney to the elevator. The doors opened.

“Y’all going down?” he asked the people inside. “Y’all care to ride with a body?”

Debbie Murphy waits for her husband, Jim Murphy, and undertaker Dan Ridener to remove a coffin from a hearse outside McCreary County Funeral Home in Whitley City, Ky. (Bonnie Jo Mount/The Washington Post)

Two dead white women now in the funeral home: Lois Maxwell in the embalming studio, Betty West in the casket room. Ridener wanted to keep them separated. He was worried the sight of too many bodies would upset members of West’s family, two of whom now walked into the funeral home.

One was West’s 20-year-old granddaughter, Kristen Chitwood, accompanied by her mother-in-law. Chitwood walked toward the body. In silence, she looked at the woman who had raised her when her own mother went to prison on drug charges, and then she touched her grandmother’s arm, red and bruised from IV lines. “I just want it to be a dream,” she said.

Ridener arrived with tissues. “What’s some of the things she did in her life?” he asked. “What kind of work did she do?”

“She was just a housewife,” Chitwood said. “She took in children that weren’t hers to raise them.”

“Did she smoke?” Ridener asked after a moment, remembering what the nurse had told him.

“She smoked off and on,” Chitwood said. “She used to smoke five packs a day.”

“A lot of them will say that it was cigarettes,” Chitwood’s mother-in-law said. “But it wasn’t that. My mother-in-law is 85, 84 and she gets around better than me and she has smoked two packs of cigarettes her whole life since she was 14, probably.”

Chitwood continued staring down at her grandmother. Nearby was a brochure listing coffins for sale. The Bronze Tribune: $4,295. The Wilbert Bronze: $4,395. The Venetian: $1,995. There would be other costs as well. Embalming would be $595. Rent for the chapel would be $495. The hearse would be $200. The services rendered by staff would be $1,750. All totaled, the cheapest funeral would be nearly $5,000. Chitwood stroked her grandmother’s hair and wondered how her family would come up with the money, while Ridener excused himself to take care of some paperwork in the office.

Only after the two visitors left did he step into the embalming studio.

He flipped on the fluorescent lights. He and an assistant wheeled out Maxwell and wheeled in West.

Ridener fitted a pinch of chewing tobacco into his mouth, and the men stretched on blue latex gloves. He walked over to two cabinets on the far wall. Each was filled with embalming chemicals. One was for drug users who “don’t embalm like a normal body” because “they’ve already got so many toxins in their system.” The other was for people such as West, who didn’t have a history of drug use.

Ridener opened five bottles and poured them into a machine, which churned them into a soupy mixture. He lifted West’s bluing body onto an aluminum table. He placed her hands in repose across her stomach. Then he pulled out a scalpel, made an incision underneath West’s collarbone, fished out an artery and inserted a tube into it that unleashed bursts of chemicals with the deliberate rhythm of a heartbeat.

“You can see the color coming back,” the apprentice said. Pinkness returned to West’s cheeks and appendages, erasing the blues. Her skin began to feel firm. Ridener started washing her scalp. “This hair is going to be a mess,” he said. “She’s got real thin hair and very little of it.”

The embalming fluid continued to cycle in, and little by little West came back to appearing as the woman she had been the day before: 59, filled with cancer and one heartbeat away from an early death.

Debbie Murphy stands outside a service at Pine Knot Funeral Home in Pine Knot, Ky. She owns that mortuary and McCreary County Funeral Home in Whitely City. Murphy knows about the rising trend of early deaths for middle-aged white women in her area, and pays attention to her health: She eats vegan meals and does Pilates. (Bonnie Jo Mount/The Washington Post)

The following day, Debbie Murphy was returning from another lunch at McCreary County’s only vegan restaurant. To Murphy, burying people has been a constant education, and one of the things she has learned from burying so many middle-aged women is that she doesn’t want to be one of them. Her own mother died at 51 of breast cancer. Then came her sister-in-law: dead at 50 when Murphy’s nephew, high on drugs and hallucinating, shot her to death in her bed. Fifty-six years old now, Murphy wears a patch on her shoulder that releases nutrients into her body. In the evenings, she practices Pilates. In the mornings, she makes a shake from a pouch of antioxidant leaf powder. And lunch is at the vegan restaurant, where she always orders the special.

Back in the funeral home now after some ratatouille, she was at her desk when a young woman walked in carrying a pair of blue jeans, a white button-down shirt, a black tank top and a pair of gold hoop earrings.

“And you are?” Murphy asked.

“Erica,” the woman said. She was Erica Leach, Maxwell’s only daughter, who had come to drop off clothing for her mother’s burial.

She handed over the bundle of clothing, and Murphy unfurled the jeans. They were well-worn. The white shirt had cigarette-burn holes on the front.

“I didn’t really want a pair of jeans, but I kind of got what I could get,” Leach said. “That’s the only jewelry I could get. I mean, I don’t even know if she could even fit in this stuff. I mean, I found the clothes I could, so . . .”

“Well, let’s see,” Murphy said.

“I had an outfit picked out for her, but it wasn’t there. Or I couldn’t find it,” Leach said, beginning to stammer, and then explained that right after her mother died, her house had been broken into, and “the whole house is like disheveled and everything.”

“Do you have any idea of why, or who?” Murphy asked.

“She has been prone to, like, she does have a reputation,” Leach said of her mother’s chronic drug use. Maybe the thieves were after drugs, maybe it was money. Maybe it was retribution. Whatever the reason, Leach had photographs of what they had done. One showed a door ripped off its hinges and thrown across the living room. Another showed a ransacked kitchen. A third showed her own childhood bedroom, also ransacked, which was where her mother had taken to sleeping lately at the end of a life that hadn’t gone according to plan: a car accident that led to a prescription for pain relievers, some mental health issues and more pills, a divorce and more pills, arrest after arrest and always more pills, until the end.

There was a silence, and Leach explained that she wasn’t living with her mother anymore, that she was in college and spending the summer in Lexington: “I’m majoring in psychology and minoring in international studies, and I’m going to get a Japanese certificate.”

“Really?” asked an employee who had been listening. “You know Japanese?”

“I can already speak a little of it,” Leach said. “And I’ve been through 101 and 102, and it’s one of my backup plans to teach English in Japan.”

Murphy and Ridener looked at her for a long moment, quietly measuring the distance between a daughter who had gotten away and a mother who had died alone in that daughter’s bed.

“Are you driving back up?” Ridener asked her.

“I’m driving to Corbin,” she said of the town where her mother had lived and died. “I’ll be here tomorrow.”

Ridener nodded and watched her leave.

Undertaker Dan Ridener, left, and apprentice Israel Clark prepare a coffin in the embalming room in Pine Knot, Ky. Samples of vaults are on display outside, at a range of prices. Many cost thousands of dollars. (Bonnie Jo Mount/The Washington Post)

The next morning, he was still thinking about what Leach had said. “That little girl going to college is a breakthrough,” he said. He was standing in the embalming room. The funeral home was quiet and empty. It was his favorite time of day, before more families walked in with more tragedy, before other employees showed up. “It’s a huge accomplishment,” he said, and then he turned his attention to her mother.

It was time to get her ready.

He started with the blue jeans Leach had brought. “These pants are not going to fit,” he said, trying to pull them up over a body that was stiff to the touch. He tried again, tugging a little. “I really believe these jeans didn’t belong to her, but to that little girl.” He tugged harder. “There’s no way.” But he got them on, buttoned her into the shirt with the cigarette burns and added the black tank top over that.

“That adds a lot more class to that shirt, and it hides the pants,” he said.

Next, he wheeled in her coffin. He fluffed its pink pillow and laid her body inside. He shaped her blond hair and slid the gold hoop earrings through her ears. An assistant arrived with a bottle of red nail polish.

“All right now, get to painting,” Ridener said.

“Ain’t nothing going to make her nails look good,” the assistant said, scrubbing away at a lifetime spent in this place. “I’m trying to get this dirt off.”

“Okay,” Ridener said after the job was done. “She’s ready.”

Two hours later, the first family member to show up for Maxwell’s funeral was Leach. She walked into the funeral home, saw the coffin propped open in the chapel and decided not to go in until it had been closed. “Everyone else can go in,” she said. “I don’t want to see it.”

More people began arriving, including several women who remained outside, smoking cigarettes and drinking Mountain Dew. “We got to figure out what we’re doing, because I didn’t bring enough cigarettes,” one of the women said to her daughter.

Some of Leach’s college friends arrived, too, and they were nearby Leach when an old man in cowboy boots recognized her.

“You still making good grades in school, Erica?” he asked.

Now a skinny woman came over, knelt down, whispered condolences and went back to her cigarettes.

From the back, the undertaker watched it all. He watched as the friends and relatives of Maxwell folded themselves into the pews, then rose again when the service was finished and went back outside to their cigarettes. He was there to advise the pallbearers who nearly dropped the coffin when placing it inside the hearse, and then he was driving the hearse deep into the countryside, into a terrain of hills and hollows and little else, until he came upon a cemetery so small and so remote it didn’t have an address.

“It was a good funeral,” he would say later, when he had a moment to think about it, “a good funeral,” but for now he had to hurry. It was late afternoon, and he had a long drive back to McCreary Funeral Home, where Betty West awaited. He didn’t have much time to prepare. The funeral of one dead white woman was over, and in a few hours, the next one would begin.

The McCreary County gravesite of Lois Maxwell — who died at 44 — at a cemetery so small and remote that it does not have an address. (Bonnie Jo Mount/The Washington Post)

Dan Keating and Julie Tate in Washington contributed to this report.