Meningeal worm (Parelaphostrongylus tenuis) is an important cause of mortality of elk (Cervus canadensis) in populations in the eastern US and has been implicated in the failure of several restoration attempts. From 2011 to 2013, the Missouri Department of Conservation translocated 108 adult and yearling elk from Kentucky (US) to southern Missouri (US) to establish a free-ranging population. From release in spring 2011 through August 2015, we monitored 167 elk (adult, yearling, and calf) to determine causes of mortality. Of 78 mortalities, 26 (33%) were linked to meningeal worm based on necropsy results and/or observed behavior; this group included 19 elk with confirmed or suspected cases of meningeal worm infection that died of other proximate causes. Other important mortality sources included euthanasia (n=11, 14%), emaciation (n=7, 9%), and predation (n=5, 6%). Eleven of the 26 (42%) meningeal worm-related mortalities were adults, and 22 (85%) were female. Meningeal worm was an important cause of mortality during the restoration of Missouri elk, potentially contributing to the loss of 16% of the monitored individuals. Greater mortality in adult female elk could reduce initial population growth by limiting reproductive output in the restored herd, especially given that females were disproportionately affected in Missouri. Because translocated Missouri elk undoubtedly were exposed to meningeal worm in Kentucky, our results could be explained by exposure to a different genetic strain of meningeal worm once in Missouri, loss of immune response due to translocation, increased dose of larval worms, or some unquantified factor.