LEWISTOWN, Pa. — The phone rang over the gurgle of embalming fluid as Geoff Burke wearily eyed the corpse of the woman on the gurney. Another victim of the coronavirus, she’d have to wait. On the phone, a nurse delivered the news: body pickup needed.

Passing the cremation oven, still hot from the morning’s use, Burke changed from his plastic embalming apron to a necktie and collared shirt as Sunday football commentators bantered on the television. As he prepared the hearse outside, his phone rang again. Second body pickup needed at a nursing home outside Lewistown. Coronavirus again.

“It’s just scary,” said Burke. ”I don’t know if this stuff is different where it hits places, but we’re just getting the worst.”

The unrelenting phone calls, the long hours, the back-to-back funeral ceremonies, the deaths, the virus, the grief have become part of Burke’s daily rhythm at the Heller-Hoenstine funeral home here in the county seat of rural Mifflin County since early November, when things first started getting bad.

In April, as the coronavirus gripped portions of southeastern Pennsylvania, western and central counties like Mifflin remained largely unaffected. But within the first weeks of December, it’s been the tiny central Pennsylvania county — with nearly three dozen COVID-19 deaths this month — that has seen the highest coronavirus death rate per capita in the commonwealth.

As the first wave of coronavirus cases ravaged urban hubs like Philadelphia and New York City in the spring, rural Pennsylvania hospitals planned and waited. But many residents bristled at COVID-19 restrictions, not yet seeing the devastation firsthand. Mask wearing was often seen as political, and the mitigation efforts frivolous in towns largely untouched by the virus.

But now, it has arrived.

Led by Mifflin, coronavirus death rates this month are on the rise in most Pennsylvania counties. Blair County, where not a single death was reported in the early April surge, has seen 52 in the first two weeks of December. Westmoreland’s total jumped sixfold, from 15 to 93.

Since inheriting his family’s funeral home business in the tiny central Pennsylvania manufacturing borough of Lewistown over a decade ago, Burke, 45, is no stranger to being knuckle-deep in death before noon. But these days, as the coronavirus wreaks havoc in his rural hometown north of the Juniata River, things are different.

“It came out of nowhere,” said Burke, whose three funeral homes handle about 25 deaths in a typical November, but last month saw 61. In the first weeks of December, he’s seen 40. And counting.

“Three months ago,” he said, “I was not really concerned about what’s happening right now. Our suppliers told us to get ready. And you know, we got ready that way, but mentally, we had no clue this was going to happen.”

Nowadays, Burke said, he and his brother-in-law spend half an hour rearranging the bodies in the back freezer room to make space for more. The coroner keeps calling, offering a refrigeration truck to hold the corpses.

“I pray to God we don’t have to bring one in,” he said.

Seventy miles west of Lewistown, Conemaugh Nason Medical Center sits among church steeples and red barns in Roaring Spring, Blair County, a 45-bed, rural hospital used to the steady rhythms of the flu and broken bones. The hospital, about 55 miles south of State College, even leases some of its land to local farmers.

“Soybeans are planted to the north of the hospital,” said Timothy Harclerode, the hospital’s CEO. “It’s corn to the south.”

In the first two weeks of April, the county reported no COVID-19 deaths, but it didn’t last. Within the first two weeks of December, 52 people have died of the virus there.

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The hospital averaged about 14 overnight patients a day, pre-coronavirus, in 2019. For the last two months, the average jumped to 30.

According to the state’s data, the first confirmed death in Blair County happened on May 12. By that date, Philadelphia had already endured more than 1,250 deaths.

Still, across the state, hospitals prepared for the rush, canceling elective surgeries, getting as much PPE as possible, and turning to tele-health appointments instead of in-patient visits.

But as the pandemic raged elsewhere, some questioned virus mitigation measures, chalking mask wearing and restaurant and gym closures up to politics as the 2020 election approached.

“There’s people who don’t know anyone who has the virus here and they think the media’s got it blown out of proportion,” said Bryan Sipes, who runs a roadside barbecue stand down the street from Conemaugh Nason, where medical staff brace for a Christmas in the COVID-19 ward. “There’s people who’ve got it and recovered and 85-year-old people who have lung issues and got it and they died.”

Sipes said his roadside business has picked up during the pandemic, but it hasn’t made up for money he’s lost.

“Most of my business was catering. All of that was canceled,” he said.

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Sipes said he does not wear a mask.

“I just can’t,” he said.

Dawn Greene, a dental assistant who lives in Hollidaysburg, said she never left the house without a mask on since March. She still contracted COVID-19, heading to the emergency room on Thanksgiving. She said she’s still dealing with ramifications from the virus.

Greene, who voted for President Donald Trump, said she was frustrated at how divisive and symbolic masks became in her area.

“Everybody thinks it’s their freedoms being taken away and things like that,” Greene, 43, said. “But trust me, if you got as sick as I was, you would wear a mask. You would get it. I get very upset when I hear people downplay it. I wouldn’t wish this on anyone.”

Of the 150 deaths in Blair, 114 were in November and December.

In Westmoreland County — which saw 15 deaths in early April, compared to 93 in the first weeks of December — attitudes toward the virus are similarly mixed as some officials rail against Gov. Tom Wolf’s temporary restrictions limiting indoor dining and gatherings. Still, Scottdale funeral home owner Frank Kapr says he’s seen changing outlooks on the virus after people or their families have been personally impacted.

“There were those who said, ‘You know this is political, after the election it’s gonna go away,’ and I said, ‘No I don’t think so ... you’re fooling yourself into this, this COVID-19 is real,’ ” said Kapr, president of the Pennsylvania Funeral Directors Association and director of his family’s funeral home for the last 40 years.

Though he watched the virus take hold in Harrisburg, Philadelphia, and New Jersey in the spring, “I never even imagined that we would get bombarded.”

“The only thing I can say to people now is, use your mask wherever you go, and stay safe,” he said.

It’s the wearing of masks and other mitigation efforts employed in Philadelphia — like limiting indoor dining and gatherings — that Dr. Debra Bogen, director of the Allegheny County Department of Health, encouraged the residents to emulate last week during a news conference. Allegheny County, currently a hotbed for cases in the commonwealth, saw 46 fatalities in the first weeks of April, and 217 within the first weeks of December — an increase mainly attributed to community spread, Bogen said. Philadelphia saw 173 deaths in the first weeks of December, down from 354 in early April.

Like many public health officials around the state, Bogen encouraged the county to stay firm in mitigating the spread while they wait their turn for a vaccine, calling it “the light at the end of the tunnel we’ve all been looking for and hoping for these last number of months.”

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At Conemaugh Nason, employees were receiving their first doses of the vaccine on Friday, and Harclerode said many were uneasy about the coming holidays and how it would affect patients. At times, when COVID-positive patients had similar timelines and symptoms, the hospital would place two in one room.

“We tried to give them someone to talk to,” he said.

Harclerode said he believes there was “COVID fatigue” in rural areas, that eventually, residents simply began to gather again. The hospital saw spikes after July 4th, Labor Day, and Thanksgiving and anticipates one after Christmas.

“There’s typically very few patients and staff here on Christmas, " he said. “That won’t be the case this year.”

Nine months into the pandemic and state-mandated coronavirus restrictions, no matter how many times Kapr has to tell grieving families that only 10 people may attend an indoor funeral ceremony, the pain is always fresh.

“I know most of my families, and I know them very well,” he said. “And it’s difficult for me to sit on the other side of the desk and tell them that this is what we have to do. They say, what about our grandchildren? It’s tough.”

The work is hard, and emotionally taxing, said Burke, the funeral home director in Mifflin. And it’s hardest when he has to cremate or embalm a friend or acquaintance from his hometown, where everybody knows everybody. But he’s taken just two days off in the last two months, despite a recent foot of snow, despite the stress, arriving at his office before the sun comes up. He said he wouldn’t quit now, that he owes it to the people in the borough to give them the send-offs they deserve.

“We’re just trying to do what’s right, you know,” he said. “We work hard so we can sleep well at night.”

Staff writers Justine McDaniel and Laura McCrystal contributed to this story.