This study examines the health system factors associated with completed suicide among veterans older than 65 years. All root cause analysis reports of suicides that occurred between 2008 and 2010 in the Veterans Health Administration were reviewed, of those, 46 reports were for those 65 years or older. The average age in the sample was 76.96 years, all were men. Method of suicide, stressors, previous attempts, root causes, and action plans designed to address the root causes are reported.