Objective: Data on services use, characteristics, and geographic distribution of homeless individuals who died in Philadelphia from 2009 to 2011 provided perspective on assessments of the homeless population that rely on conventional counts and surveys.

Methods: Data from the City of Philadelphia Medical Examiner’s Office were used to parse homeless decedents into three groups on the basis of use of homelessness services (known users, occasional users, and nonusers), and differences among the groups were assessed by using descriptive and multivariate methods.

Results: Of 141 adult decedents, 49% made substantial use of the homelessness services system (known users), 27% made occasional use of these services (occasional users), and 24% had no record of use of homelessness services (nonusers). Compared with known users, nonusers and occasional users were less likely to have had a severe mental illness diagnosis or to have received either disability benefits or Medicaid coverage and were more likely to be white. Nonusers and occasional users were also more likely than known users to have died in outlying parts of the city.

Conclusions: More conventional homeless surveys and enumerations miss a substantial portion of the homeless population. Including these “hidden homeless” persons would alter perceptions about the composition of Philadelphia’s homeless population, lowering estimates of the incidence of psychiatric disability and increasing estimates of racial diversity.