Ruffed Grouse (Bonasa umbellus) populations have declined in much of the eastern US in recent decades. Research suggests that West Nile virus (WNV) contributed to these declines, based on decreasing population indices temporally correlated to WNV introduction into North America, high morbidity and mortality in experimentally infected Ruffed Grouse, and relatively low statewide seroprevalence concurrent with high WNV vector indices. We describe lesions and relevant diagnostic findings in six, free-ranging Ruffed Grouse that directly or indirectly died of natural WNV infection and compare results to experimentally infected Ruffed Grouse. All naturally infected grouse were found moribund or dead from August to December 2015–18 in the northeastern US; 4/6 grouse were subadults. Necropsy, histopathology, immunohistochemistry, and/or ancillary tests contributed to the diagnosis of WNV-associated disease in all cases. The most common lesions in naturally infected grouse were myocardial inflammation, degeneration, and/or necrosis, consistent with lesions in experimentally infected grouse. Evidence of trauma in 6/6 naturally infected grouse suggests the possibility of WNV-associated morbidity as a predisposing factor. Diagnostic findings in 3/6 naturally infected grouse were consistent with experimentally infected grouse with severe disease 7–8 d postinoculation; the remaining naturally infected birds had similar findings to experimentally infected subclinical grouse. Our results further support the notion that WNV contributes to mortality of free-ranging Ruffed Grouse and may be used to improve surveillance strategies and population-level management approaches.