Four men developed silicosis after sandblasting tombstones for an average of 35 months; 3 of them died an average of 59 months after their first exposure to sandblasting. Lung tissue demonstrated noncaseating granulomas and silicotic nodules involving small arteries and veins in 3 patients and alveolar proteinosis in 2. X-ray energy spectrometry showed primarily elemental silicon in the lung parenchyma. One patient developed lupus erythematosus and another focal glomerulonephritis. Two developed pneumothorax. None had cultural or morphologic evidence of tuberculosis. Pulmonary function studies in all 4 patients revealed a restrictive pattern. Industrial investigations revealed that the patients wore inadequate personal protection equipment and were exposed to 5 times the threshold limit value for respirable silica.