The death toll from a 6.2 magnitude earthquake jumped to at least 241, revised down from 247, on Thursday as rescuers struggle to find survivors in flattened villages of Italy.
Officials say the death toll might rise as an unknown number of people remain trapped under collapsed buildings.
The quake that hit near the town of Norcia, in the region of Umbria, left at least 368 injured, Prime Minister Matteo Renzi said.
Emergency services staff and volunteers were determined to pull out more survivors from the ruins, but this has proved difficult as several settlements are hard to reach.
"There are still so many people under masonry, so many missing," said Immacolata Postiglione, the head of the Italy's civil protection unit.
Rescuers working with emergency lighting saved a 10-year-old girl who remained in the ruins for some 17 hours in the hamlet of Pescara del Tronto.
Hundreds of people had to spend a chilly night in tents and shelters to avoid aftershocks that could be dangerous if they returned home.
The authorities were called to find shelter for some 2,000 people.
"Tonight will be our first nightmare night," said Alessandro Gabrielli in the town of Amatrice.
Along with Amatrice, the worst-hit towns are Accumoli, Posta and Arquata del Tronto, fire department spokesman Luca Cari told Reuters.
The quake was powerful enough to be felt in Rome 150 kilometres (90 miles) away, as well as Bologna.
Amatrice’s mayor Sergio Pirozzi said rescuers digging through ruins at a hotel that collapsed in the city, which was hosting about 70 guests when the quake struck, had only recovered seven of bodies.
"Half the village has disappeared," Pirozzi said.
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Many of the people killed or reported missing are believed to be visitors.
"Today is a day for tears, tomorrow we can talk of reconstruction," he told reporters late on Wednesday.
In 2009, an earthquake in Italy struck the central city of L'Aquila killing more than 300 people, raising issues over the authorities failing to warn citizens.
David Rothery, Professor of Planetary Geosciences at Britain's Open University, said the quake was too sudden to predict.
"Unlike the L'Aquila quake, which was preceded by swarms of smaller quakes and led to claims -- unjustified in my view -- that the eventual big quake should have been predicted, this one appears to have struck out of the blue."